A nurse is assessing a client who has received treatment for hypocalcemia. Which of the following findings indicates the treatment has been effective?
Moist mucous membranes
Negative Chvostek's sign
Weight gain
Urine output 25 mL/hr
The Correct Answer is B
A. Moist mucous membranes: While moist mucous membranes may indicate adequate hydration, they are not specific to the treatment of hypocalcemia. The goal of hypocalcemia treatment is to correct calcium levels in the body, which would be reflected by the resolution of clinical signs related to low calcium, such as Chvostek's sign.
B. Negative Chvostek's sign: Chvostek's sign is a clinical sign that suggests hypocalcemia, where tapping the facial nerve causes twitching of the facial muscles. A negative Chvostek's sign indicates that calcium levels have normalized, meaning the treatment for hypocalcemia has been effective. The absence of this sign is a reliable indicator that the treatment has corrected the calcium deficiency.
C. Weight gain: Weight gain is not a typical or direct indicator of hypocalcemia treatment success. While some treatments for hypocalcemia might impact overall metabolism, weight gain is not a specific or reliable sign of calcium normalization. The most relevant sign would be the absence of symptoms related to calcium deficiency, such as a negative Chvostek’s sign.
D. Urine output 25 mL/hr: Urine output of 25 mL/hr is below the normal threshold, which is typically at least 30 mL/hr. While urine output can be affected by various factors, it is not a reliable marker for effective treatment of hypocalcemia. Treatment success is better assessed by signs related to calcium levels, such as the negative Chvostek’s sign, rather than urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Feedings should begin within 1 hr after birth. Initiating feeding within the first hour of life supports early bonding and helps stabilize the newborn’s blood glucose. This applies to both breastfed and bottle-fed infants and is considered a key component of newborn care.
B. Feedings can be controlled by gravity. Bottle feedings should not rely solely on gravity, as this can increase the risk of overfeeding and aspiration. Instead, caregivers should hold the bottle at an angle and watch for feeding cues, allowing the infant to suck and swallow at their own pace.
C. Feedings should be on demand. While on-demand feeding is typically encouraged with breastfeeding, bottle feeding is generally guided by scheduled intervals (e.g., every 3–4 hours) early on. Over time, bottle-fed infants may show hunger cues, but structured timing helps regulate intake initially.
D. Feedings may occur in clusters. Cluster feeding is common with breastfeeding due to variable milk flow and infant comfort needs. Bottle-fed infants usually have more consistent feeding patterns and are less likely to feed in unpredictable clusters.
Correct Answer is ["A","E"]
Explanation
A. Remove the solution from the refrigerator 1 hr before infusing: Allowing the TPN solution to warm to room temperature helps reduce the risk of vein irritation and discomfort. Cold solutions can cause venospasm or systemic reactions when infused into the bloodstream.
B. Increase the rate of the infusion as needed to keep it on schedule: TPN must be administered at a consistent prescribed rate. Increasing the rate without orders can lead to hyperglycemia, fluid overload, or metabolic complications. Any delays should be reported to the healthcare provider.
C. Weigh the client every other day: Daily weight monitoring is essential in TPN therapy to assess fluid balance and nutritional status. Weighing the client only every other day may delay the recognition of fluid overload or dehydration.
D. Change the client's TPN catheter tubing every 72 hr: TPN tubing should be changed every 24 hours to reduce the risk of catheter-related bloodstream infections. Extending beyond this time frame increases the likelihood of microbial contamination.
E. Infuse TPN through a central venous line: Due to its high glucose and osmolarity content, TPN must be administered via a central line to prevent phlebitis and allow for rapid, well-tolerated infusion. Peripheral administration is not suitable for long-term TPN.
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