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 D

Explanation

A. While monitoring oxygen saturation is important, ensuring an open airway takes priority.
B. Administering oxygen is important, but ensuring an open airway is the initial priority.
C. Checking the pulse rate is important, but ensuring an open airway is the initial priority.
D. Correct. Establishing a patent airway is the most critical action for a client with compromised breathing and cyanosis.

A. Initiate droplet precautions. B. Administer granulocyte colony-stimulating factor. C. Educate the infant's guardians about exchange transfusions. D. Monitor the infant's lymphocyte count.

Correct Answer is D

Explanation

A. Droplet precautions are not indicated for HIV; standard precautions should be followed.
B. Granulocyte colony-stimulating factor is typically used to increase white blood cell production and is not directly related to HIV care.
C. Exchange transfusions are not a routine intervention for infants with HIV.
D. Correct. Monitoring the infant's lymphocyte count is important to assess immune function and response to HIV treatment.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Correct Answer is D

Explanation

A nurse is assisting with the plan of care for a 10-month-old Infant who has HIV. Which of the following Interventions should the nurse Include in the plan?

Correct Answer is D

Explanation

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