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

The correct answer is choice C.

Choice A rationale:

The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.

Choice B rationale:

The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.

Choice C rationale:

The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.

Choice D rationale:

The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.

Choice A rationale:

Circulatory overload, also known as hypervolemia or fluid overload, is a condition where the body has too much fluid. This excess fluid, especially in the circulatory system, can lead to a rapid heartbeat. This is because the heart needs to work harder to pump the increased volume of blood, leading to an increased heart rate.

Choice B rationale:

Weight loss is not typically associated with circulatory overload. In fact, quick weight gain might be observed due to the excess fluid in the body.

Choice C rationale:

Low blood pressure is not a common symptom of circulatory overload. On the contrary, high blood pressure can occur because the excess fluid in the circulatory system puts more pressure on the blood vessel walls.

Choice D rationale:

Excessive sweating is not a direct symptom of circulatory overload. However, symptoms such as shortness of breath and swelling in certain areas of the body are more common.