A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?
Dry mucous membranes
Trousseau's sign
Hyperactive reflexes
Irregular heart rate
The Correct Answer is D
Hyperkalemia refers to an elevated level of potassium in the blood. It can have various manifestations, and one of the critical effects of hyperkalemia is its impact on cardiac function. High levels of potassium can disrupt the normal electrical conduction in the heart, leading to arrhythmias or irregular heart rate. These arrhythmias can range from mild palpitations to more severe and life-threatening conditions like ventricular fibrillation.
Dry mucous membranes are more commonly associated with dehydration or reduced fluid intake. Hyperkalemia does not directly cause dry mucous membranes.
Trousseau's sign is a clinical manifestation of hypocalcemia, not hyperkalemia. It is characterized by carpal spasm induced by inflating a blood pressure cuff above the client's systolic blood pressure for a few minutes.
Hyperactive reflexes are commonly seen in conditions such as hyperthyroidism or certain neurologic disorders. They are not directly related to hyperkalemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
A. Increased erythrocyte sedimentation rate
A. Increased erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. In the presence of an infection, the ESR tends to rise due to increased levels of acute-phase reactants, such as fibrinogen and globulins. However, it is important to note that an increased ESR alone does not diagnose a specific infection but rather indicates the presence of inflammation or infection.
Decreased platelets in (option B) should not be included because they are not typically associated with infection. Low platelet levels (thrombocytopenia) may occur due to various reasons, such as certain medications, immune disorders, or bone marrow problems, but they are not directly linked to infections.
Increased iron level in (option C) should not be included because it is not a typical finding in an active infection. In fact, during an infection, iron levels tend to decrease in response to the body's efforts to withhold iron from pathogens, as most microorganisms require iron for their growth and survival.
Decreased haemoglobin in (option D) should not be included because it is not directly indicative of an infection. A decrease in hemoglobin levels may be associated with conditions such as anaemia, blood loss, or certain chronic diseases, but it is not a specific marker for infection.
Correct Answer is C
Explanation
Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.
Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.
Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.
Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.
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