A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

A. Glucagon is administered to increase blood glucose levels in hypoglycemic states. However, the client's glucose level is within the normal range (72 mg/dL), so administering glucagon is not appropriate.

B. Chvostek's sign is assessed to detect hypocalcemia, not hypokalemia. It involves tapping the facial nerve anterior to the earlobe and observing for facial muscle contraction. This action is not relevant to the potassium level and is not indicated based on the laboratory findings provided.
C. The client's potassium level of 3.0 mEq/L is below the normal range, indicating hypokalemia. Potassium replacement is essential to prevent complications such as cardiac arrhythmias. The nurse should follow the facility's protocol for administering potassium replacement, which may include adjusting the TPN solution or administering intravenous potassium supplements.
D. Discontinuing the TPN infusion is not warranted based solely on the potassium level. The TPN infusion provides essential nutrition and should not be stopped without addressing the electrolyte imbalance separately.

A. Nocturnal enuresis refers to nighttime bedwetting. In clients with paraplegia and neurogenic bladder, nocturnal enuresis can occur due to impaired bladder sensation or control. However, it does not necessarily indicate the immediate need for catheterization unless accompanied by significant bladder distension or discomfort.
B. Suprapubic discomfort or pain suggests bladder distension, which can occur when the bladder fills beyond its capacity. In clients with neurogenic bladder, this discomfort can be an indication that the bladder needs to be emptied to prevent overdistension and potential complications such as urinary retention or bladder rupture. Therefore, suprapubic discomfort may indicate the need for catheterization.
C. Urge incontinence refers to the sudden and uncontrollable urge to urinate, which leads to involuntary leakage of urine. In clients with neurogenic bladder, urge incontinence can occur due to involuntary bladder contractions. While it indicates an inability to control bladder function, it may not always necessitate immediate catheterization unless it persists or is accompanied by other symptoms.
D. Reflex incontinence occurs when the bladder empties without the person's control due to a spinal cord injury or neurological condition. In clients with paraplegia, reflex incontinence is often managed through intermittent catheterization programs. If reflex incontinence episodes are frequent or result in inadequate bladder emptying, it may indicate the need for more frequent catheterization.