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
Explanation
A. Take this medication between meals.
Iron supplements like ferrous gluconate are absorbed better on an empty stomach. Taking them between meals or one hour before meals, with a glass of orange juice (which contains vitamin C and enhances iron absorption), helps improve absorption.
B. Limit intake of Vitamin C while taking this medication.
This is incorrect. Vitamin C enhances iron absorption and is often recommended to be taken with iron supplements.
C. Take this medication with milk.
Taking iron supplements with milk is not recommended because calcium in milk can interfere with iron absorption.
D. Limit intake of whole grains while taking this medication.
Whole grains contain phytates, which can inhibit iron absorption. Therefore, it's a good idea to avoid consuming large amounts of whole grains with iron supplements.
Correct Answer is D
Explanation
A. "Do you take any recreational drugs?"
This question is related to the risk of hepatitis transmission through the sharing of needles or other drug paraphernalia. Hepatitis B and C can be transmitted through contaminated needles used for injecting drugs.
B. "Did you have a blood transfusion recently?"
This question addresses the risk of hepatitis transmission through blood transfusions. While this used to be a significant risk, modern blood screening procedures have greatly reduced this risk. However, it's still a relevant question to understand the client's medical history.
C. "Have you eaten any shellfish lately?"
This question is related to the risk of hepatitis A transmission. Hepatitis A is often transmitted through contaminated food or water. Shellfish from contaminated waters can be a source of hepatitis A infection.
D. "Have you traveled to a third world country in the past two months?"
This question is crucial because hepatitis A is often more prevalent in developing countries and can be contracted through contaminated food, water, or poor sanitation. Travel history can help identify possible exposure sources.
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