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

Choice A reason: Measuring seizure duration is critical for medical management, as prolonged seizures (over 5 minutes) may require emergency intervention like anticonvulsants. Timing helps assess severity and guides treatment, prioritizing safety and data collection over unnecessary restraint, aligning with evidence-based practice.

Choice B reason: Restraining arms and legs during a seizure risks injury like fractures or dislocations, as tonic-clonic movements are involuntary and forceful. Safety involves clearing the area, not restricting motion, since restraint opposes neurological protocols, increasing harm rather than protecting the client.

Choice C reason: Lowering side rails during a seizure increases fall risk, as tonic-clonic activity can propel the client off the bed. Keeping rails up, padded if possible, ensures safety by containing movement, contradicting this action’s utility, as evidence prioritizes preventing trauma.

Choice D reason: Inserting an oral airway during a seizure is dangerous; clenched jaws can break teeth or the device, risking aspiration. Airway management occurs post-seizure if needed, not during, as neurological guidelines emphasize protection without invasive actions causing injury.

Choice A reason: Every 2 hours for wheezing is incorrect; montelukast is daily, not PRN. Scientifically, it’s a leukotriene inhibitor for prevention, not acute relief, showing misunderstanding of its chronic asthma management role versus rescue inhalers.

Choice B reason: Once daily in the evening is correct for montelukast, optimizing its anti-inflammatory effect overnight. Scientifically, this aligns with pharmacokinetics and asthma’s nocturnal worsening, indicating accurate understanding of its administration for long-term control.

Choice C reason: Stopping with steroids is wrong; montelukast complements, not replaces, them. Scientifically, it targets different pathways (leukotrienes vs. corticosteroids), and combined use enhances control, reflecting a misgrasp of its additive role in asthma therapy.

Choice D reason: Two months for efficacy is false; montelukast acts within days. Scientifically, its leukotriene blockade reduces inflammation quickly, not over months, suggesting misunderstanding of its rapid onset in asthma symptom prevention per evidence.