A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs?

Reference Range:

Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

Measure blood pressure in both arms.

Assess skin turgor for elasticity.

Observe the skin for signs of bruising.

Note the rhythm of the pulse.

Answer and Explanation

The Correct Answer is D

A.   While it is generally good practice to measure blood pressure in both arms for a comprehensive assessment, this is not the primary concern with hypocalcemia. Hypocalcemia primarily affects neuromuscular and cardiovascular systems, so while blood pressure monitoring is important, it does not directly address the critical symptoms associated with low calcium levels.
B.   Assessing skin turgor is a useful practice for evaluating hydration status and skin elasticity but is not specifically related to the management or symptoms of hypocalcemia. In hypocalcemia, skin changes are not the most relevant concern compared to neuromuscular symptoms.
C.   Hypocalcemia can increase the risk of bleeding and bruising due to impaired blood clotting mechanisms. Monitoring for bruising can be an important aspect of assessing the effects of low calcium levels on the client’s hemostatic function. Bruising can be a direct indicator of the impact of hypocalcemia on blood coagulation and is relevant to the clinical management of the condition.
D.   Hypocalcemia can affect cardiac function, potentially leading to changes in heart rhythm and rate. Monitoring the rhythm of the pulse is crucial, as it can help identify arrhythmias or other cardiac disturbances associated with low calcium levels.

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Correct Answer is A

Explanation

A. It's normal for the reservoir bag not to deflate completely during inspiration. A respiratory rate of 14 breaths/minute is within the normal range (12-20 breaths/minute). If the client is comfortable and their oxygen saturation is within the normal range, there is no need for intervention. Documenting the assessment data for future reference is sufficient.
B. Increasing the liter flow of oxygen may not be necessary if the client's oxygen saturation is within the normal range. It could also lead to oxygen toxicity if the flow is set too high.
C. Encouraging deep breaths may not be necessary if the client's respiratory rate is within the normal range.
D. Removing the mask to deflate the bag is not necessary and could interfere with the delivery of oxygen.

A. Initiate infusion for an IV fluid bolus. B. Administer an IV antiemetic. C. Medicate with PRN IV narcotic. D. Discourage straining on stool.

Correct Answer is C

Explanation

A. While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B. Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C. The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D. This is not relevant to the client's current symptoms of severe pain and nausea.

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A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs? Reference Range: Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs?

Reference Range:

Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]