Nokea
The client is in renal failure.
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?
- A. Dry mucous membranes
- B. Hyperactive reflexes
- C. Trousseau's sign
- D. Irregular heart rate
Correct Answer: D
Rationale: Irregular heart rate is a hallmark of hyperkalemia due to its effect on cardiac conduction.
You may also like to solve these questions
A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?
- A. Elevated ammonia
- B. Elevated lipase
- C. Prolonged PT/INR
- D. Decreased albumin
Correct Answer: B
Rationale: Elevated lipase is a specific marker of pancreatitis.
A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
- A. Moves objects to mouth
- B. Anterior fontanel closed
- C. Rolls from back to abdomen
- D. Posterior fontanel closed
Correct Answer: B
Rationale: Anterior fontanel closure before 12-18 months may indicate abnormal development.
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?
- A. Encourage the client to use the overbed trapeze.
- B. Maintain abduction of the client's residual limb with a pillow.
- C. Caution the client to avoid a prone position while in bed.
- D. Keep a loose, absorbent dressing over the client's surgical site.
Correct Answer: A
Rationale: Using the trapeze builds upper body strength for mobility.
The client consumed alcohol 2 days after taking disulfiram.
A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
- A. Constipation
- B. Dry skin
- C. Hypotension
- D. Urinary retention
Correct Answer: C
Rationale: Disulfiram-alcohol reaction causes hypotension among other symptoms.