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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Using proper body mechanics is vital to prevent injury and ensure safe lifting. Key principles include keeping the back straight and neutral to reduce spinal stress and bending at the knees and hips to engage stronger leg muscles rather than the lower back. Maintaining a shoulder-width stance provides stability, while holding objects close to the body decreases spinal strain. Lifting with the legs, not the back, further protects the spine. Twisting should be avoided—pivoting with the feet maintains alignment and reduces injury risk. Keeping the head and neck aligned with the spine improves posture and visual focus. Using smooth, controlled movements prevents muscle strain and dropped objects. Assessing an object’s weight before lifting helps determine if help or equipment is needed, preventing overexertion. Supportive footwear with a good grip ensures balance and minimizes fall risk. These ergonomic practices promote safety, reduce injuries, and are essential in both clinical and everyday environments.
Correct Answer is A
Explanation
A. “Morphine 3 mg subcutaneous every 4 hr PRN for pain.": This entry uses correct and safe medication documentation practices. It includes the drug name, dose without trailing zero, full route written out, frequency, and indication, reducing the risk of misinterpretation.
B. “Morphine 3 mg SC q 4 hr PRN for pain,": Abbreviations like “SC” and “q” are discouraged by The Joint Commission due to the potential for misreading. The full words "subcutaneous" and "every" are preferred for clarity and safety.
C. “Morphine 3.0 mg sub q every 4 hr PRN for pain.": The trailing zero (“3.0 mg”) increases the risk of dosage error if the decimal point is not seen. Safe practice omits trailing zeros in medication doses.
D. “Morphine 3 mg SQ every 4 hr PRN for pain.": The abbreviation “SQ” can be mistaken for “SL” (sublingual) or “5Q,” leading to errors. The route should be written out fully as “subcutaneous” to ensure clear communication.
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