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: Reflex incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder is overfilled and the sphincter relaxes. Reflex incontinence can be managed by following a regular catheterization schedule, not by waiting for symptoms.
Choice B reason: Urge incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder contracts involuntarily and the sphincter cannot prevent leakage. Urge incontinence can be managed by using anticholinergic medications, bladder training, or pelvic floor exercises, not by catheterization.
Choice C reason: Nocturnal enuresis is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs during sleep. Nocturnal enuresis can be managed by limiting fluid intake before bedtime, using an alarm device, or taking desmopressin, not by catheterization.
Choice D reason: Suprapubic discomfort is a sign of the need to catheterize the client, as it indicates bladder distension and possible urinary retention. Suprapubic discomfort can be relieved by draining the urine from the bladder using a catheter.
Correct Answer is C
Explanation
Choice A reason: The nurse applies the sterile drape prior to cleansing the perineal area. This is a correct action by the nurse, as it helps to prevent contamination of the catheter insertion site and maintain a sterile field.
Choice B reason: The nurse coats the indwelling urinary catheter with lubricant. This is a correct action by the nurse, as it helps to ease the insertion of the catheter and reduce the risk of trauma or infection.
Choice C reason: The nurse separates the client's labia with her dominant hand. This is an incorrect action by the nurse, as it violates the principle of sterile technique. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and use her dominant hand to hold the catheter. The non-dominant hand should not touch anything else after separating the labia, as it is considered contaminated.
Choice D reason: The nurse provides perineal care prior to inserting the urinary catheter. This is a correct action by the nurse, as it helps to reduce the bacterial load and prevent infection. The nurse should use soap and water to cleanse the perineal area from front to back, and use a new washcloth for each stroke.
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