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 B

Explanation

A. While documenting the color and clarity of the urine is important for assessing the client's urinary output and potential issues, it is not the immediate next step in the catheter insertion process. This step typically comes after the catheter is fully inserted and secured.
B. Once urine flow is observed, the next step is to inflate the balloon of the indwelling catheter to secure it in place within the bladder. This ensures the catheter remains correctly positioned and does not move out of the bladder, which is crucial for effective drainage and preventing accidental dislodgement.
C. Asking the client to breathe deeply and exhale does not impact the catheterization process and is not related to the next immediate step after observing urine flow. This action might be helpful in other contexts, such as reducing anxiety or discomfort, but it does not address the technical steps required for catheter insertion.
D. If urine flow is observed in the catheter, it indicates that the catheter is already in the bladder. Inserting the catheter an additional inch is unnecessary and could potentially cause trauma or discomfort. Proper catheter placement is confirmed by the observation of urine flow, and additional insertion is not required.

A. Report the findings to the healthcare provider. B. Review the client's current electrolyte values. C. Demonstrate the use of an incentive spirometer. D. Connect the tube to low intermittent suction.

Correct Answer is A

Explanation

A. Reporting the findings to the healthcare provider is crucial in this situation. The combination of fever and dyspnea could indicate a serious complication such as aspiration pneumonia or an infection related to the tube feeding. Prompt communication with the healthcare provider ensures that the client receives timely evaluation and treatment.
B. While monitoring electrolytes is important in the context of tube feedings (to ensure proper balance and prevent imbalances), the symptoms of fever and dyspnea are more urgent concerns that need immediate attention.
C. Using an incentive spirometer can be beneficial for improving lung function and preventing complications like atelectasis, especially if the client has respiratory issues. However, this action is more appropriate for clients who have specific respiratory therapy needs and is not the first step in addressing acute symptoms like fever and dyspnea, which require a more immediate response.
D. Connecting the tube to low intermittent suction might be used to manage gastric residuals or to help with gastrointestinal decompression in some situations, but it does not address the acute symptoms of fever and dyspnea.

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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)]

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Naxlex Comprehensive Predictor Exams

While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

Correct Answer is B

Explanation

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Correct Answer is A

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)]