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 A

Explanation

Choice A reason: Metoprolol, a beta-blocker, lowers BP, causing orthostatic hypotension. Caution when standing prevents falls, showing grasp of this key side effect.

Choice B reason: Leafy greens affect warfarin, not metoprolol. No dietary restriction applies, so this reflects confusion about beta-blocker side effects.

Choice C reason: Weight gain, not loss, may occur with metoprolol from fluid retention. Expecting loss misinterprets its metabolic impact, indicating misunderstanding.

Choice D reason: Taste loss isn’t a metoprolol effect; it’s linked to other drugs. This shows incorrect attribution of side effects to the medication.

A. "I will bathe my baby under a faucet of running water." B. "I will wash my baby's face with a warm, wet washcloth without soap." C. "I will wash my baby's head using a moist towelette." D. "I will give my baby a bath every day."

Correct Answer is B

Explanation

Choice A reason: Bathing under running water risks temperature instability and drowning in newborns. This is unsafe, showing a lack of proper care understanding.

Choice B reason: Washing the face with a warm, wet washcloth without soap protects delicate skin, avoiding irritation. This aligns with newborn hygiene best practices.

Choice C reason: Moist towelettes often contain chemicals, unsuitable for newborn scalps. Warm water and cloth are gentler, so this reflects misunderstanding of care.

Choice D reason: Daily baths dry out newborn skin, increasing irritation risk. Spot cleaning is advised, making this an incorrect application of hygiene teaching.

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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?

Nursing Test Bank

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