A nurse is collecting data on a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?
Wheezing
Decreased deep tendon reflexes
Hypoactive bowel sounds
Cerebral edema
The Correct Answer is B
The correct answer is B. Decreased deep tendon reflexes. Hyperkalemia can lead to muscle weakness and decreased reflexes, which is a common manifestation in patients with chronic kidney disease.
Choice A reason:
Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not hyperkalemia. Hyperkalemia affects the muscular function and cardiac conduction rather than causing respiratory symptoms.
Choice B reason:
Decreased deep tendon reflexes occur due to the effect of hyperkalemia on the neuromuscular junction and muscle excitability. In hyperkalemia, the resting membrane potential of muscle cells is less negative, which makes them less responsive to stimuli.
Choice C reason:
Hypoactive bowel sounds are generally associated with gastrointestinal issues and are not a direct manifestation of hyperkalemia. While severe hyperkalemia can affect smooth muscle function, it is not typically characterized by changes in bowel sounds.
Choice D reason:
Cerebral edema is not a manifestation of hyperkalemia. It is usually caused by traumatic brain injury, infections, or other neurological conditions. Hyperkalemia primarily affects muscular function and cardiac conduction.
Normal serum potassium levels range from about 3.5 to 5.0 mmol/L. Hyperkalemia is defined as serum potassium levels above 5.0 mmol/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: You should not expect your stoma to be a purple color. A purple stoma indicates ischemia or necrosis, which are serious complications that require immediate medical attention. A healthy stoma should be pink or red and moist.
Choice B reason: Your colostomy will produce formed stool, depending on the location of the colostomy. A sigmoid colostomy is located in the lower part of the large intestine, where most of the water is absorbed from the stool. Therefore, the stool from a sigmoid colostomy will be more solid and regular than from other types of colostomies.
Choice C reason: The end of the stoma will not be painful after this procedure. The stoma is made from the lining of the intestine, which does not have nerve endings that sense pain. However, the skin around the stoma may be sore or irritated from the surgery or the appliance.
Choice D reason: You will have a stoma in your left lower abdomen. A sigmoid colostomy is created by bringing the end of the sigmoid colon, which is the last segment of the large intestine, through an opening in the left lower quadrant of the abdomen. The stoma is then attached to the skin and covered with an appliance that collects the stool.
Correct Answer is D
Explanation
Choice A reason: Flank pain is not a sign of an allergic transfusion reaction. Flank pain is a pain in the side of the abdomen or back, usually caused by kidney problems, such as infection, stones, or injury. Flank pain can be a sign of a hemolytic transfusion reaction, which is a serious complication that occurs when the donor blood is incompatible with the recipient's blood type.
Choice B reason: Elevated blood pressure is not a sign of an allergic transfusion reaction. Elevated blood pressure is a condition where the force of the blood against the artery walls is too high, which can increase the risk of heart disease, stroke, and kidney damage. Elevated blood pressure can be a sign of a hypertensive transfusion reaction, which is a rare complication that occurs when the donor blood has a higher sodium level than the recipient's blood.
Choice C reason: Distended neck veins are not a sign of an allergic transfusion reaction. Distended neck veins are a sign of increased pressure in the right side of the heart or the superior vena cava, which can be caused by heart failure, pulmonary hypertension, or obstruction. Distended neck veins can be a sign of a circulatory overload transfusion reaction, which is a complication that occurs when the blood volume or rate of infusion is too high for the recipient's cardiovascular system.
Choice D reason: Wheezing is a sign of an allergic transfusion reaction. Wheezing is a high-pitched whistling sound that occurs when the airways are narrowed or inflamed, which can cause difficulty breathing, coughing, or chest tightness. Wheezing can be a sign of an allergic transfusion reaction, which is a hypersensitivity response to the donor blood or its components, such as plasma proteins, antibodies, or preservatives. An allergic transfusion reaction can range from mild to severe, and can be treated with antihistamines, corticosteroids, or epinephrine.
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