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

Dry mucous membranes

Hyperactive reflexes

Trousseau's sign

Irregular heart rate

Answer and Explanation

The Correct Answer is D

Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.

Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.

Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.

Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.

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Correct Answer is C

Explanation

Choice A reason: Erythromycin is specified, so the medication is clear. No ambiguity exists here for clarification. Scientifically, drug identity is explicit, and errors arise elsewhere, making this unnecessary to question unless a different antibiotic was intended, which isn’t suggested.

Choice B reason: Dosage (500 mg) is precise, with no range or units needing clarification. Scientifically, this is a standard erythromycin dose, aligning with therapeutic norms for infections, leaving little room for error unless misheard, which isn’t indicated.

Choice C reason: Route (e.g., oral, IV) isn’t stated, critical for erythromycin, as administration affects bioavailability and efficacy. Scientifically, unclear delivery risks under- or overdosing, necessitating provider clarification to ensure safe, effective treatment per pharmacological standards.

Choice D reason: Time (four times daily) is clear, aligning with erythromycin’s pharmacokinetics for steady levels. Scientifically, frequency is unambiguous, requiring no clarification unless intervals were vague, which they aren’t, making this less urgent than route.

A. Asking the client to point their toes before applying the stockings B. Ensuring that creases in the stockings are on the front of the client’s legs C. Turning the stockings inside out before applying them D. Applying the stockings before the client gets out of bed

Correct Answer is B

Explanation

Choice A reason: Pointing toes eases stocking application, reducing drag on skin. Scientifically, this aligns with proper technique, enhancing venous return without resistance, so no intervention is needed, as it supports effective antiembolic function per guidelines.

Choice B reason: Creases on the front risk pressure sores or impaired circulation, countering antiembolic goals. Scientifically, smooth application prevents venous stasis, requiring intervention, as this error compromises blood flow and skin integrity in at-risk clients.

Choice C reason: Turning stockings inside out aids application, a standard technique for even fit. Scientifically, this ensures proper compression gradient, supporting venous return, so no intervention is warranted, as it’s correct per procedural evidence.

Choice D reason: Applying before getting out of bed maximizes compression benefits, reducing clot risk. Scientifically, this aligns with prophylaxis timing, as gravity aids swelling post-ambulation, making it appropriate and not requiring nurse intervention.

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

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Naxlex Comprehensive Predictor Exams

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