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
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.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. Incorrect. Decreased platelets are not typically associated with infection but can be indicative of bleeding disorders.
B. Incorrect. Increased iron levels are not directly related to infection but can be associated with conditions like hemochromatosis.
C. Correct. An increased erythrocyte sedimentation rate (ESR. is it a common indicator of inflammation and infection? It reflects the rate at which red blood cells settle in a tube over a specific period.
D. Incorrect. Decreased hemoglobin levels are not specific to infection but can be seen in various conditions, including anemia.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should identify that the client is at risk of developing heart failure and may require further assessment and intervention.
Heart failure is suggested by the progressive decline in vital signs and laboratory results, such as increasing BUN and creatinine levels, which indicate worsening kidney function and can contribute to heart failure. The client’s fatigue, weakness, bilateral edema, and crackles in the lungs are clinical signs consistent with heart failure. The dry, flaky skin and coarse, thinning hair also reflect systemic issues that could be associated with heart failure and poor nutritional status.
The nurse should focus on further assessment to evaluate the severity of heart failure and intervention to manage symptoms, potentially including medication adjustments, fluid management, and additional diagnostic testing. These steps are crucial to addressing the client’s deteriorating condition and preventing further complications.
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