A nurse is caring for a client on the medical-surgical unit. Laboratory Results. Vital Signs - Day 1 - 1200: Temperature 100.9°F (38.2°C), Respiratory Rate 26/min, Heart Rate 109/min, Blood Pressure 89/58 mmHg, Pain Score 9/10. Day 2 - Medication Administration - 0700: Temperature: 98.6°F (37°C), Heart Rate 98/min, Respiratory Rate 20/min, Record, Pain Score: 2/10, Blood Pressure 111/62 mmHg. Nurses' Notes - Vital Signs. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Hypocalcemia.

Hypernatremia.

Hyperkalemia.

Potential Condition. Action to Take 1: Prepare to check a serum albumin level. Action to Take 2: Request a STAT ECG. Parameters to Monitor 1: Serum bicarbonate level. Parameters to Monitor 2: Intake and Output.

Answer and Explanation

The Correct Answer is A

Hypocalcemia. Action to Take 1: Prepare to check a serum albumin level.

Rationale:

Hypocalcemia can be influenced by changes in serum albumin levels, as calcium may bind to albumin. Correcting calcium levels based on albumin can help determine the actual calcium status. Action to Take 2: Request a STAT ECG. Rationale: Hypocalcemia can lead to prolonged QT intervals on an electrocardiogram (ECG). A STAT ECG is necessary to assess cardiac function and detect any potential arrhythmias. Parameters to Monitor 1: Serum bicarbonate level. Rationale: Monitoring serum bicarbonate levels can help assess the client's acid-base balance and metabolic status. Abnormal bicarbonate levels may indicate metabolic disturbances. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to evaluate the client's fluid balance and kidney function. Hypocalcemia can impact renal function, and assessing urine output is crucial.

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Correct Answer is A

Explanation

Hypocalcemia. Action to Take 1: Prepare to check a serum albumin level.

Rationale:

A. Contraction of the facial muscles. B. Complaints of fingers tingling. C. Carpal spasm with blood pressure measurement. D. Asked when the foot numbness would go away.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

The nurse considered contraction of facial muscles as a finding of hypocalcemia because it is associated with Chvostek's sign, which indicates neuromuscular irritability due to low calcium levels.

Choice B rationale:

Complaints of fingers tingling are indicative of hypocalcemia since tingling sensations (paresthesias) in the extremities can result from decreased calcium levels affecting nerve function.

Choice C rationale:

Carpal spasm with blood pressure measurement is known as Trousseau's sign and is associated with hypocalcemia. When the blood pressure cuff is inflated above systolic pressure, it can cause tetany in the hand if the calcium levels are low.

Choice D rationale:

Asking when foot numbness would go away does not directly relate to hypocalcemia or its symptoms. It is not a finding used to come to the conclusion of hypocalcemia in this scenario.

Choice E rationale:

The heart rate being 88 and regular does not directly indicate hypocalcemia. While hypocalcemia can lead to cardiac arrhythmias, a heart rate of 88 and regular is within the normal range and not a specific finding for hypocalcemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select All that Apply.).

A patient with chronic renal failure has an occluded arteriovenous fistula, and routine hemodialysis is delayed. However, the patient's serum potassium level is 6.0 mEq/L. What should the nurse expect to be prescribed for this patient? Select all that apply.

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG?

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?

A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

A patient has a serum phosphate level of 4.7 mg/dL. Which treatments should the nurse expect to be prescribed for this patient? Select all that apply.

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient's healthcare provider?