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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: A heart murmur is a common finding in clients who have mitral valve stenosis. It is a sound produced by turbulent blood flow through the narrowed valve. The murmur is usually heard as a low-pitched rumbling sound during diastole.

Choice B reason: Bradycardia is not a typical finding in clients who have mitral valve stenosis. Bradycardia is a slow heart rate, usually below 60 beats per minute. Mitral valve stenosis can cause tachycardia, which is a fast heart rate, due to increased cardiac workload and reduced cardiac output.

Choice C reason: Clubbing of the fingers is not a sign of mitral valve stenosis. Clubbing is a deformity of the fingertips and nails that occurs due to chronic hypoxia. Mitral valve stenosis can cause pulmonary hypertension and pulmonary edema, which can impair gas exchange, but not to the extent of causing clubbing.

Choice D reason: Barrel chest is not a sign of mitral valve stenosis. Barrel chest is a condition where the chest is enlarged and rounded due to chronic lung disease. Mitral valve stenosis can affect the lungs by increasing the pressure in the pulmonary circulation, but it does not cause structural changes in the chest wall.

A. Don sterile gloves before inserting the indwelling urinary catheter. B. Apply an oil-based lubricant to the indwelling urinary catheter. C. Test the balloon on the indwelling urinary catheter before insertion. D. Use one cotton swab to clean the client's urinary meatus.

Correct Answer is A

Explanation

Choice A reason: Donning sterile gloves is an essential step to prevent contamination and infection during the insertion of an indwelling urinary catheter. The nurse should also use aseptic technique and a sterile catheter kit.

Choice B reason: Applying an oil-based lubricant to the indwelling urinary catheter is not recommended, as it can damage the latex material and increase the risk of catheter-associated urinary tract infection (CAUTI). The nurse should use a water-soluble lubricant instead.

Choice C reason: Testing the balloon on the indwelling urinary catheter before insertion is a good practice, as it ensures that the balloon is functioning properly and does not leak or burst. The nurse should inflate and deflate the balloon with sterile water or saline using a syringe.

Choice D reason: Using one cotton swab to clean the client's urinary meatus is not sufficient, as it may not remove all the bacteria and debris. The nurse should use at least three cotton swabs and clean the meatus from front to back in a circular motion. The nurse should also use an antiseptic solution such as chlorhexidine or povidone-iodine.

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A nurse is collecting data on a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is collecting data on a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?

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