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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. "I will consume less caffeine and spicy foods."
This statement is correct. Avoiding caffeine and spicy foods can help reduce stomach acid and prevent irritation, which is beneficial for individuals with hiatal hernia.
B. "I will sleep with the head of my bed elevated."
This statement is correct. Elevating the head of the bed can help prevent stomach acid from flowing back into the esophagus while sleeping, reducing symptoms like heartburn.
C. “I will lie down for one-half hour after meals."
This statement is incorrect. It's advisable for individuals with hiatal hernia to remain upright for at least two to three hours after meals to allow gravity to aid digestion and prevent acid reflux.
D. “I will drink less fluid."
This statement is incorrect. Adequate hydration is important for overall health. Drinking water between meals (not during meals) is generally recommended for individuals with hiatal hernia to prevent excess stomach distension during meals.
E. “To gain weight.”
This statement is not directly related to dietary recommendations for hiatal hernia. Weight gain or loss would depend on the individual's overall health goals and is not specific to managing hiatal hernia symptoms.
Correct Answer is ["10"]
Explanation
To calculate the number of milliliters (mL) of the hydroxyzine oral suspension to administer, you can use the following formula:
Dose (mL) = Ordered Dose (mg)/ Stock Concentration (mg/mL)
In this case:
- Ordered Dose = 50 mg
- Stock Concentration = 25 mg/5 mL
First, calculate the mg per mL from the stock concentration:
mg per mL = 25 mg/ 5 mL= 5 mg/mL
Now, use the formula to find the mL to administer:
Dose (mL) = 50 mg/ 5 mg/mL = 10 mL
So, the nurse should administer 10 mL of hydroxyzine oral suspension.
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