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.

A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.

When interpreting test results, particularly for an infectious disease like tuberculosis (TB), the nurse must prioritize specific infection control measures to prevent the spread of the disease.

The correct actions are:

• Wear an N95 respirator mask: This mask is essential for protecting the nurse and others from inhaling airborne pathogens that the client with TB might expel.
• Place the client in a room with negative air pressure: This type of room ensures that airborne contaminants do not escape into the hallway or other areas, thereby containing the infection and protecting others in the healthcare facility.

These measures are critical in managing the spread of TB and ensuring the safety of both healthcare workers and other patients.