A nurse is collecting data on a patient who has chronic kidney disease.
Which finding is a sign of hyperkalemia?

Choice A rationale:

Requesting a prescription for a stool softener from the provider could be a potential solution, but it’s not the first step. Medications should be considered when lifestyle modifications and dietary changes are not effective.

Choice B rationale:

Incorporating more fluids and fiber into the patient’s diet is the most appropriate action. Constipation in older adults can be caused by dehydration and not eating enough. Dietary fiber adds bulk to the diet and is capable of absorbing water, which helps to soften the stool and promote regular bowel movements. Therefore, increasing fluid and fiber intake is often the first step in managing constipation.

Choice C rationale:

Encouraging the patient to engage in active range-of-motion exercises might not directly alleviate constipation. While physical activity is generally beneficial for overall health, increased exercise does not improve symptoms of constipation in nursing home residents or older adults.

Choice D rationale:

Advising the patient to avoid foods that cause gas might help if the patient has bloating or gas, but it won’t necessarily address the issue of constipation. The focus should be on increasing fiber and fluid intake.

Choice A rationale:

A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.

Choice B rationale:

Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.

Choice C rationale:

A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.

Choice D rationale:

Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.