A nurse is collecting data on a patient who has chronic kidney disease.
Which finding is a sign of hyperkalemia?

The correct answer is Choice A: Don sterile gloves before inserting the indwelling urinary catheter.

Choice A rationale:

Donning sterile gloves is crucial to prevent infection during the insertion of an indwelling urinary catheter. Maintaining aseptic technique is essential to avoid introducing pathogens into the urinary tract.

Choice B rationale:

Applying an oil-based lubricant to the catheter is not recommended as it can interfere with the sterility of the procedure and potentially cause irritation or infection.

Choice C rationale:

Testing the balloon before insertion is important, but it is not the first step in the process. The priority is to ensure that the nurse is using sterile gloves to maintain aseptic technique.

Choice D rationale:

Using one cotton swab to clean the patient’s urinary meatus is not sufficient for proper aseptic technique. The area should be cleaned thoroughly with appropriate antiseptic solutions and sterile supplies.

The correct answer is: B. Decreased deep tendon reflexes.

Choice A rationale: Wheezing is not typically associated with hyperkalemia. It is more commonly related to respiratory conditions.

Choice B rationale: Hyperkalemia can cause decreased deep tendon reflexes due to the effect of high potassium levels on nerve conduction and muscle function.

Choice C rationale: Hypoactive bowel sounds are not a common sign of hyperkalemia. They are more often associated with gastrointestinal issues.

Choice D rationale: Cerebral edema is not related to hyperkalemia. It is usually associated with conditions affecting the brain, such as trauma or infections.