A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

Muscle weakness

Oliguria

Hypoactive bowel sounds

Hypertension

Answer and Explanation

The Correct Answer is A

A. Muscle weakness: Hyperkalemia disrupts normal muscle cell function by affecting membrane excitability, leading to symptoms like muscle weakness or even paralysis in severe cases. It is one of the hallmark signs of elevated potassium levels.
B. Oliguria: While hyperkalemia may be associated with renal impairment, oliguria is not a direct manifestation of high potassium but rather a possible contributing factor. It is not specific to hyperkalemia itself.
C. Hypoactive bowel sounds: Increased potassium levels typically cause hyperactivity of the gastrointestinal tract, leading to hyperactive bowel sounds and cramping, not reduced or hypoactive activity.
D. Hypertension: Hyperkalemia more commonly results in hypotension due to its effects on cardiac conduction and vasculature. Hypertension is not a typical manifestation of elevated serum potassium.

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Correct Answer is B

Explanation

A. Match the client’s blood type with the type and cross match specimen: Type and crossmatching are important for allogeneic transfusions, but in autologous transfusions, the focus is on ensuring the unit belongs to the client rather than compatibility testing.
B. Ensure that the client's identification band matches the number on the blood unit: Verifying the client’s ID band against the unique number on the autologous blood unit ensures the right blood is given to the right person, preventing serious transfusion errors.
C. Confirm the provider's prescription matches the number on the blood component: The provider’s order is important, but it does not confirm the identity of the recipient. Matching the blood unit to the client’s ID is more critical for safety.
D. Ask the client to state his blood type and the date of the blood donation: Relying on client self-report is unreliable, especially in high-stress settings. Identification should always be confirmed using objective, verifiable identifiers like wristbands and blood unit labels.

A. Ham sandwich with milk B. Scrambled eggs and toast with milk C. Shrimp salad and tomato soup with milk D. Bacon and cheese quiche with milk

Correct Answer is B

Explanation

A. Ham sandwich with milk: Ham is pork, which is prohibited in kosher dietary laws. Additionally, mixing meat and dairy in the same meal is not allowed in kosher practice.
B. Scrambled eggs and toast with milk: Eggs, bread, and milk are all considered kosher when prepared properly, and this combination avoids mixing meat and dairy. This option aligns with kosher dietary restrictions.
C. Shrimp salad and tomato soup with milk: Shrimp is a shellfish and is not kosher. Kosher dietary laws prohibit the consumption of shellfish and other non-scaled seafood.
D. Bacon and cheese quiche with milk: Bacon is derived from pork, which is forbidden in kosher diets. Additionally, this meal mixes meat and dairy, which is also not permitted under kosher rules.

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A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

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