A nurse is collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia.

Dry mucous membranes

Irregular heart rate

Hyperactive reflexes

Trousseau's sign

Answer and Explanation

The Correct Answer is B

A.   Incorrect. Dry mucous membranes are not typically associated with hyperkalemia.
B.   Correct. Hyperkalemia can lead to cardiac dysrhythmias, including irregular heart rate.
C.   Incorrect. Hyperactive reflexes are more commonly associated with hypokalemia (low potassium levels.
D.   Incorrect. Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia.

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Correct Answer is C

Explanation

A. Discarding worksheets containing client information in a wastebasket does not ensure proper disposal of confidential information and could compromise confidentiality.
B. Writing a client's diagnosis on the message board in the client's room could breach confidentiality, as it could potentially be seen by unauthorized individuals.
C. This action protects client confidentiality because it involves discussing sensitive information in a private setting where unauthorized individuals are less likely to overhear. This is an appropriate method of communicating client information during a handoff.
D. While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.

A. Ask the client if they would like to watch television. B. Use short, simple sentences when speaking with the client. C. Allow the client to have 1 hr of time alone in their room. D. Move the client to a table where other clients are playing cards.

Correct Answer is B

Explanation

A. Incorrect. Offering to watch television may not address the client's agitation and anxiety effectively.
B. Correct. The client's behaviors suggest anxiety or agitation. Using short, simple sentences when speaking with the client can help reduce their stress and facilitate communication.
C. Incorrect. While some clients may benefit from alone time, it's important to assess the client's preferences and needs. Isolating the client in their room might not be the best approach if they are seeking engagement.
D. Incorrect. Moving the client to a group setting may increase their discomfort or agitation. It's important to consider the client's current emotional state and tailor interventions accordingly.

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A nurse is collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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