A nurse is collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia.

Dry mucous membranes

Irregular heart rate

Hyperactive reflexes

Trousseau's sign

Answer and Explanation

The Correct Answer is B

A.   Incorrect. Dry mucous membranes are not typically associated with hyperkalemia.
B.   Correct. Hyperkalemia can lead to cardiac dysrhythmias, including irregular heart rate.
C.   Incorrect. Hyperactive reflexes are more commonly associated with hypokalemia (low potassium levels.
D.   Incorrect. Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia.

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Correct Answer is B

Explanation

A. Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B. Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.

A. The client is assigned to a room with negative airflow. B. The client's meal tray includes ice cream with fresh fruit. C. The client has artificial flowers in the room. D. The client's meal tray contains hard-boiled eggs.

Correct Answer is B

Explanation

A. A room with negative airflow helps prevent the spread of airborne pathogens, which is helpful for immunocompromised clients like those with HIV, but it doesn't directly increase the risk of infection.
B. Correct. Neutropenic clients have reduced immune responses, and consume fresh fruit (which might carry bacteria. can increase the risk of infection.
C. Artificial flowers might be removed due to infection control concerns, but their presence doesn't significantly increase infection risk.
D. Hardboiled eggs are not necessarily a high-risk food for infection in neutropenic clients.

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A nurse is collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia.

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