The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia?
Cardiac arrhythmia
Seizure
Dyspnea
Oliguria
The Correct Answer is A
Choice A reason:
Cardiac arrhythmia is a primary clinical manifestation of hyperkalemia. Hyperkalemia, defined as an elevated level of potassium in the blood, can significantly affect the electrical activity of the heart. This can lead to various types of arrhythmias, including bradycardia, ventricular tachycardia, and even cardiac arrest1. The presence of arrhythmias is a critical indicator of hyperkalemia and requires immediate medical attention to prevent life-threatening complications.
Choice B reason:
Seizures are not typically associated with hyperkalemia2. While severe electrolyte imbalances can potentially lead to neurological symptoms, seizures are more commonly linked to conditions such as hyponatremia (low sodium levels) or hypocalcemia (low calcium levels). Therefore, seizures are not a primary sign of hyperkalemia.
Choice C reason:
Dyspnea, or difficulty breathing, can occur in various medical conditions, including heart failure and respiratory disorders. While hyperkalemia can lead to muscle weakness and fatigue, which might indirectly affect breathing, dyspnea is not a primary clinical manifestation of hyperkalemia. The main concern with hyperkalemia is its effect on cardiac function.
Choice D reason:
Oliguria, or reduced urine output, is a symptom of acute renal failure but not specifically indicative of hyperkalemia. While acute renal failure can lead to hyperkalemia due to the kidneys’ inability to excrete potassium, oliguria itself is not a direct sign of hyperkalemia. The focus should be on the cardiac effects of elevated potassium levels
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Feeding an infant with gastroesophageal reflux formula instead of breast milk is not necessary. Breast milk is often easier for infants to digest and can be beneficial for reducing reflux symptoms. According to the American Academy of Pediatrics, breastfeeding should be continued if possible, as it has numerous health benefits for both the infant and the mother. If formula feeding is necessary, specialized formulas designed for infants with reflux can be used, but this does not mean breast milk should be avoided.
Choice B reason:
Thinning the baby’s formula with water is not recommended. This practice can dilute the essential nutrients in the formula, leading to inadequate nutrition for the infant. Instead, thickening agents such as rice cereal can be added to the formula to help reduce reflux symptoms. This approach helps the formula stay down in the stomach and reduces the likelihood of regurgitation.
Choice C reason:
Positioning the baby side-lying during sleep is not recommended for infants with gastroesophageal reflux. The American Academy of Pediatrics advises that infants should be placed on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Side-lying or prone positions are not safe for sleep and do not effectively reduce reflux symptoms.
Choice D reason:
Keeping the baby in an upright position after feedings is the correct approach for managing gastroesophageal reflux. This position helps prevent the stomach contents from flowing back into the esophagus, reducing the likelihood of reflux. It is recommended to hold the baby upright for at least 20-30 minutes after feeding to allow gravity to assist in keeping the stomach contents down.
Correct Answer is C
Explanation
Choice A reason:
Performing an ultrasound to determine if there is urinary retention is not the immediate priority action. While an ultrasound can help assess urinary retention, the presence of edema, redness, and the foreskin being behind the glans penis suggests a condition known as paraphimosis. Paraphimosis is a medical emergency that requires prompt attention to prevent complications such as tissue damage. Therefore, alerting the ER physician is the priority action.
Choice B reason:
Asking the parents specifically how long the infant has not voided is important for gathering information, but it is not the immediate priority action. The clinical signs of edema, redness, and the foreskin being behind the glans penis indicate a potential emergency that requires immediate medical intervention. While obtaining a detailed history is important, the nurse should first alert the ER physician to ensure timely management.
Choice C reason:
Alerting the ER physician to the patient’s condition is the correct priority action. The presence of edema, redness, and the foreskin being behind the glans penis suggests paraphimosis, which is a urological emergency. Prompt intervention is necessary to reduce the foreskin and restore normal blood flow to prevent tissue damage3. The ER physician can provide the necessary treatment and management for this condition.
Choice D reason:
Continuing to monitor the patient in the ER setting is not appropriate without first addressing the potential emergency. The signs of edema, redness, and the foreskin being behind the glans penis indicate a condition that requires immediate medical attention. Monitoring alone is insufficient; the nurse must alert the ER physician to ensure prompt intervention.
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