A client who received 6 units of packed red blood cells 3 days ago for a lower gastrointestinal (GI) bleed is now displaying signs of shortness of breath with occasional stridor and is reporting muscle cramping.

Reference Range:
Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
Magnesium [Adult: 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L)]
Calcium [9 to 10.5 mg/dL (2.3 to 2.6 mmol/L)]
Sodium (136 to 145 mEq/L (136 to 145 mmol/L)]

Which serum laboratory value should the nurse immediately report to the healthcare provider?

Potassium 4.7 mEq/L (4.70 mmol/L).

Magnesium 2.1 mEq/L (0.86 mmol/L).

Calcium 6.5 mg/dL (1.63 mmol/L).

Sodium 135 mEq/L (135 mmol/L).

Answer and Explanation

The Correct Answer is C

Choice A reason: Potassium 4.7 mEq/L (4.70 mmol/L) is within the normal reference range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Potassium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high potassium level (hyperkalemia) can cause muscle weakness, irregular heartbeat, and cardiac arrest. A low potassium level (hypokalemia) can cause muscle cramps, fatigue, and arrhythmias.

Choice B reason: Magnesium 2.1 mEq/L (0.86 mmol/L) is within the normal reference range of 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Magnesium is an electrolyte that helps regulate the activity of enzymes, muscles, and nerves, as well as the balance of calcium and potassium in the body. A high magnesium level (hypermagnesemia) can cause nausea, vomiting, flushing, muscle weakness, and respiratory depression. A low magnesium level (hypomagnesemia) can cause muscle twitching, tremors, seizures, and cardiac arrhythmias.

Choice C reason: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range of 9 to 10.5 mg/dL (2.3 to 2.6 mmol/L). Calcium is an electrolyte that helps regulate the function of muscles, nerves, bones, and blood clotting. A high calcium level (hypercalcemia) can cause nausea, vomiting, constipation, confusion, kidney stones, and bone pain. A low calcium level (hypocalcemia) can cause muscle spasms, cramps, tingling, numbness, and stridor (a high-pitched sound when breathing). **This is a critical value that should be immediately reported to the healthcare provider**, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.

Choice D reason: Sodium 135 mEq/L (135 mmol/L) is slightly below the normal reference range of 136 to 145 mEq/L (136 to 145 mmol/L). Sodium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high sodium level (hypernatremia) can cause thirst, dry mouth, confusion, seizures, and coma. A low sodium level (hyponatremia) can cause headache, nausea, vomiting, fatigue, muscle weakness, and confusion.

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Correct Answer is D

Explanation

Choice A reason: Measuring capillary glucose level is not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Corticosteroids can increase blood glucose levels, but this is not an urgent concern in this situation.

Choice B reason: Encouraging ambulation in the room is not appropriate for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Ambulation can worsen the pain and inflammation, and increase the risk of bowel perforation.

Choice C reason: Monitoring for bloody diarrheal stools is important for a client with IBD, but not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Bloody stools can be a sign of ulceration or bleeding in the bowel, but they are not specific to peritonitis.

Choice D reason: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, which can guide the appropriate interventions and treatments.

A. Restriction of caloric intake. B. Fewer fingerstick glucose checks. C. Higher doses of insulin. D. Increased oral fluid intake.

Correct Answer is C

Explanation

Choice A reason: Restriction of caloric intake is not a good change for a client with diabetes mellitus and an upper respiratory infection, because it can lead to hypoglycemia and malnutrition. The client needs adequate calories to maintain blood glucose levels and support immune function. Therefore, this choice is incorrect.

Choice B reason: Fewer fingerstick glucose checks are not a good change for a client with diabetes mellitus and an upper respiratory infection, because they can lead to poor blood glucose control and complications. The client needs frequent monitoring of blood glucose levels to adjust insulin doses and prevent hyperglycemia or hypoglycemia. Therefore, this choice is incorrect.

Choice C reason: Higher doses of insulin are a good change for a client with diabetes mellitus and an upper respiratory infection, because they can help lower blood glucose levels and prevent ketoacidosis. The client needs more insulin to overcome the increased insulin resistance caused by the infection and the stress hormones. Therefore, this choice is correct.

Choice D reason: Increased oral fluid intake is a good change for a client with diabetes mellitus and an upper respiratory infection, but it is not directly related to blood glucose management. The client needs more fluids to prevent dehydration and clear mucus from the respiratory tract. Therefore, this choice is not the best answer.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?

Correct Answer is D

Explanation

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?

Correct Answer is C

Explanation

An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?

Patient Data Exhibits Specify which findings indicate early interventions for an ischemic stroke were effective? Each focused assessment area may support more than one clinical finding.

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

A patient experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?

A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?