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 ["B"]
Explanation
A. "I will expect a warm feeling when the dye is injected."
This statement is incorrect. Barium swallow involves swallowing a contrast medium, not an injection. The warm feeling might be associated with injected substances but not with a barium swallow.
B. "I will drink plenty of fluids after the test."
This statement is correct. After a barium swallow, it's important to drink plenty of fluids to help clear the barium from the body and prevent constipation.
C. "I will maintain a clear liquid diet 24 hours before the test."
This statement is incorrect. A clear liquid diet might be recommended before certain medical procedures, but for a barium swallow, often patients are asked to avoid eating or drinking for a 8hours before the test.
D. "I will expect my stool to be black after this procedure."
Barium can cause stools to appear white or light-colored for several days after the procedure.Black stools could indicate the presence of gastrointestinal bleeding or other issues unrelated to the barium swallow.
Correct Answer is D
Explanation
A. Obtain the client's vital signs:
Vital signs are essential for assessing the client's overall condition and can provide crucial information about the client's stability. However, in this scenario, there's a higher priority nursing action that needs immediate attention.
B. Weigh the client:
Daily weight measurement is important, especially in postoperative patients, to monitor for fluid retention or loss. However, this is not the most urgent action in this situation.
C. Change the client's dressing:
Changing the dressing involves maintaining the surgical site's cleanliness and preventing infections. While this is important, it's not the highest priority in this situation.
D. Administer pain medication:
Correct Choice. Addressing the client's pain is a priority to ensure their comfort and well-being, especially postoperatively. Managing pain effectively is crucial for the client's recovery and can facilitate other necessary activities, such as changing the dressing or weighing the client.
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