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 C

Explanation

A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
B. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.

A. Recommend the client spend time alone in his room. B. Suggest the client exercise before going to bed. C. Offer the client low-protein snacks throughout the day. D. Encourage the client to use positive self-talk.

Correct Answer is D

Explanation

A. Social isolation can exacerbate depressive symptoms, so it's not recommended for the client to spend time alone in his room.
B. Exercise is generally beneficial for individuals with depression, but exercising before bedtime might interfere with sleep.
C. There's no evidence to support the direct relationship between low-protein snacks and managing major depressive disorder.
D. Correct. Encouraging the client to use positive self-talk can help counteract negative thought patterns that are often present in depression.

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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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