A nurse is monitoring laboratory values for a client who is receiving hemodialysis and has a serum calcium level of 7.2 mg/dL. For which of
Hyperactive deep tendon reflexes
Hypoactive bowel sounds
Positive Chvostek's sign
Lethargy
The Correct Answer is C
Choice A: This is incorrect because hyperactive deep tendon reflexes are not associated with low serum calcium levels. Hyperactive deep tendon reflexes can indicate hypomagnesemia, hyperthyroidism, or spinal cord injury.
Choice B: This is incorrect because hypoactive bowel sounds are not associated with low serum calcium levels. Hypoactive bowel sounds can indicate ileus, peritonitis, or opioid use.
Choice C: This is correct because positive Chvostek's sign is associated with low serum calcium levels. Positive Chvostek's sign is a facial muscle spasm that occurs when tapping on the cheek near the ear. It indicates hypocalcemia, which can be caused by hemodialysis, renal failure, or parathyroid dysfunction.
Choice D: This is incorrect because lethargy is not associated with low serum calcium levels. Lethargy can indicate hypercalcemia, dehydration, hypoglycemia, or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Applying moist heat to the incision while in bed is not an appropriate instruction, as it can increase the risk of infection, bleeding, or swelling at the site. The nurse should instruct the client to keep the incision dry and covered with a sterile dressing.
Choice B reason: Performing range of motion by adducting the hip is not an appropriate instruction, as it can cause dislocation or damage to the prosthesis. The nurse should instruct the client to avoid crossing their legs or turning their toes inward and to use an abduction pillow or wedge between their legs.
Choice C reason: Sitting in a straight-backed chair is an appropriate instruction, as it can prevent flexion contractures and promote circulation and healing in the hip joint. The nurse should instruct the client to use a raised toilet seat and a chair with armrests and avoid sitting for longer than 45 min at a time.
Choice D reason: Cleansing the surgical incision with hydrogen peroxide is not an appropriate instruction, as it can irritate or damage the tissue and delay wound healing. The nurse should instruct the client to use mild soap and water or saline solution to clean the incision and pat it dry gently.
Correct Answer is C
Explanation
Choice A: This is incorrect because taking iron supplement with an antacid can reduce its absorption and effectiveness. The client should take iron supplement on an empty stomach or with a source of vitamin C to enhance its absorption.
Choice B: This is incorrect because drinking liquid iron supplement undiluted can stain the teeth and cause irritation to the mouth and throat. The client should dilute liquid iron supplement with water or juice and drink it through a straw.
Choice C: This is correct because increasing fiber intake while taking iron supplement can help prevent constipation, which is a common side effect of iron supplementation. The client should also drink plenty of fluids and exercise regularly to promote bowel movements.
Choice D: This is incorrect because notifying the doctor if stools turn black is not necessary as it is a normal and harmless effect of iron supplementation. The client should only notify the doctor if stools are tarry, bloody, or have a foul odor, which can indicate gastrointestinal bleeding.
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