A nurse is assisting with evaluating a newly licensed nurse who is draining an ileostomy bag for a client. Which of the

following actions by the newly licensed nurse indicates an understanding of the procedure?

Choice A reason: Fats help in the absorption of fat-soluble vitamins (A, D, E, and K), which is essential for various bodily functions.

Choice B reason: While fats are involved in the makeup of myelin that insulates nerve cells, they do not directly
regulate nerve cell transmission.

Choice C reason: Fats do not convert to sugar; they are broken down into fatty acids and glycerol to provide energy.

Choice D reason: Proteins are primarily responsible for building and repairing tissues, not fats.

Choice A reason: Cerebral edema is not typically a manifestation of hyperkalemia. Hyperkalemia can cause neurological symptoms due to its effect on nerve transmission, but cerebral edema is more commonly associated with conditions like traumatic brain injury, stroke, or brain tumors.

Choice B reason: Wheezing is a respiratory symptom and is not directly related to hyperkalemia. It is more commonly associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD).

Choice C reason: Hypoactive bowel sounds may indicate a gastrointestinal issue but are not a specific sign of hyperkalemia. Hyperkalemia can affect smooth muscle contraction and could potentially lead to intestinal motility issues, but this is not a primary manifestation.

Choice D reason: Decreased deep tendon reflexes can be a manifestation of hyperkalemia. Hyperkalemia affects the neuromuscular junction and can lead to muscle weakness, which may manifest as decreased reflexes. Normal potassium levels in the blood are typically between 3.5 and 5.0 millimoles per liter (mmol/L). Hyperkalemia occurs when potassium levels rise above 5.5 mmol/L.