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

• Urticaria: Urticaria (hives) is a hallmark sign of an allergic reaction, particularly latex allergy, and typically appears quickly following exposure to allergens. It is not seen in malignant hyperthermia or hypovolemic shock.
• Wheezing: Wheezing can occur in latex allergy due to bronchospasm or airway edema. While respiratory compromise may happen in malignant hyperthermia, it is typically due to muscle breakdown and CO2 retention, not bronchospasm. Wheezing is not expected in hypovolemic shock.
• Muscle rigidity: Generalized rigidity, especially of the jaw (masseter spasm), is a key early sign of malignant hyperthermia, a life-threatening reaction to certain anesthetics. It is not a symptom of latex allergy or hypovolemic shock.
• Hypercapnia: An elevated PaCO₂ is an early, sensitive marker of malignant hyperthermia, resulting from increased CO₂ production due to sustained muscle contraction. This does not occur in latex allergy or hypovolemic shock.
• Tachycardia: Elevated heart rate can be seen in all three conditions: in malignant hyperthermia due to increased metabolic demand, in latex allergy due to anaphylactic reaction, and in hypovolemic shock as a compensatory response to fluid loss.

Rationale for Correct Choices:

• Endometritis: The client has systemic signs (feeling unwell, low-grade fever), elevated WBC count, and local uterine findings indicating infection. Endometritis is a common complication postpartum, especially after cesarean birth with membrane rupture exceeding 24 hours.
• Uterus and lochia assessment: The presence of a boggy, tender uterus and foul-smelling, dark brown lochia are classic signs of endometritis. These findings, in the setting of cesarean delivery and prolonged rupture of membranes, point to uterine infection as the primary concern.

Rationale for Incorrect Choices:

• Pneumonia: The client lacks hallmark signs of pneumonia, such as productive cough, abnormal sputum, or abnormal chest auscultation like crackles or wheezing. Normal respiratory rate and oxygenation further reduce the likelihood of a lower respiratory tract infection.
• Mastitis: Typically presents with unilateral breast pain, erythema, warmth, and systemic symptoms like high fever and malaise. The client’s symptoms are more consistent with engorgement, making mastitis an unlikely cause.
• Lung sounds: While lung sounds are diminished at the bases, they are otherwise clear, and the client has normal respiratory rate and oxygen saturation. These findings do not support a diagnosis of pneumonia and may simply reflect postoperative atelectasis or limited mobility.
• Breast and nipple changes: Breast fullness and nipple discomfort are expected during lactation and suggest engorgement rather than mastitis. There is no redness, localized heat, or severe pain reported.