A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Check the client for a positive Chvostek’s sign

Discontinue the TPN infusion.

Request a potassium replace

Administer glucagon IM

Answer and Explanation

The Correct Answer is C

A. Check the client for a positive Chvostek’s sign:
Chvostek's sign is a clinical sign of hypocalcemia, not related to the given laboratory values. The symptoms include facial muscle twitching when the facial nerve (VII) is tapped. There's no indication for this assessment based on the provided information.

B. Discontinue the TPN infusion:
The glucose level is within the normal range (70-99 mg/dL). Discontinuing TPN based solely on this glucose level is not warranted.

C. Request a potassium replacement:
The potassium level is low (normal range typically 3.5-5.0 mEq/L). Given the low potassium level, the nurse should plan to request a potassium replacement. Potassium is crucial for various physiological functions, and a deficiency can lead to significant complications.

D. Administer glucagon IM:
Glucagon is used to treat hypoglycemia, but the client's glucose level is within the normal range, so administering glucagon is not indicated.

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Correct Answer is B

Explanation

A. Avoid replacing the NG tube if it is accidentally dislodged: If the NG tube is accidentally dislodged, it should be replaced to maintain gastric decompression unless contraindicated. This option is incorrect.
B. Irrigate the blue pigtail port with sterile saline.

This is the correct answer. In a double-lumen nasogastric (NG) tube, one lumen (usually blue) is used for gastric decompression (removal of gastric contents), and the other lumen (usually white) is used for air venting and irrigation. Irrigating the blue pigtail port with sterile saline is part of the nursing care to maintain tube patency and prevent blockage.
C. Verify tube placement by injecting air into the larger lumen: Tube placement verification is typically done by auscultating for air while injecting air into the smaller lumen (air venting and irrigation lumen), not the larger lumen. Injecting air into the larger lumen does not serve this purpose and can be dangerous. This option is incorrect.

D. Avoid the nares when providing hygiene care: Proper hygiene care around the nares is essential to prevent irritation and breakdown of the skin. However, this option does not specifically address the care of the NG tube itself. This option is incorrect.

Correct Answer is ["1110ml"]

Explanation

8-oz cup of coffee = 8 oz (since 1 fluid ounce is approximately 30 ml, this is roughly 240 ml).

3 oz of juice = 3 oz (approximately 90 ml).

12 oz of soda = 12 oz (approximately 360 ml).

Water pitcher had 300 ml, and 200 ml remains, so the client consumed 300 ml - 200 ml = 100 ml of water.

IV fluids infusing at 40 mL/hr for 8 hours = 40 ml/hr * 8 hr = 320 ml.

Now, sum up these values:

240 ml (coffee) + 90 ml (juice) + 360 ml (soda) + 100 ml (water) + 320 ml (IV fluids) = 1,110 ml
So, the nurse should document the client's total intake for the shift as 1,110 ml.

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A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care of a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

Correct Answer is ["1110ml"]

Explanation

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