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: Documenting infiltration records the event but does not address the immediate issue. Edema and coolness suggest fluid leakage into tissues, which can cause damage if not stopped. Documentation is secondary to halting the infusion, as it only logs data without mitigating the ongoing extravasation harming the client’s tissue integrity.

Choice B reason: Applying a warm compress may increase blood flow and reduce swelling later, but it does not stop the fluid leakage causing the edema. The priority is to cease the infusion to prevent further tissue damage from ongoing infiltration, making this a subsequent action rather than the first step.

Choice C reason: Elevating the arm can help reduce swelling by aiding venous return, but it does not address the source of the problem—fluid leaking from the IV. Stopping the infusion first prevents additional extravasation, as elevation alone cannot halt the ongoing tissue damage caused by the continuous fluid administration.

Choice D reason: Stopping the infusion is the priority because edema and coolness indicate infiltration, where IV fluid leaks into surrounding tissues. Ceasing the flow prevents further damage, such as tissue necrosis or nerve injury, which can occur if fluid continues to accumulate, making this the critical first step in management.

Choice A reason: Autonomy empowers client decision-making, not truth-telling directly. The nurse’s honesty supports it indirectly, but the act itself aligns more with ethical transparency principles.

Choice B reason: Justice ensures fair treatment, unrelated to disclosing medication effects. Truthful communication addresses individual care, not equitable resource distribution in this scenario.

Choice C reason: Veracity is truthfulness, exemplified by explaining adverse effects accurately. This builds trust and informed consent, a core ethical duty in mental health nursing.

Choice D reason: Beneficence promotes well-being, but truth-telling isn’t inherently beneficent. It’s about honesty, not just benefit, aligning with veracity over doing good in this context.