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 C

Explanation

A. Assume position with legs and rectum lower than the stomach.

Explanation: This position helps gas move through the intestines more effectively, relieving abdominal distension and promoting the passage of flatus. It's a commonly recommended position for patients experiencing discomfort due to abdominal gas.
B. Drink cold liquids.

Explanation: Drinking cold liquids might not directly help with abdominal distension and flatus. Warm liquids, on the other hand, can sometimes promote digestion and relieve gas discomfort.
C. Ambulate several times a day.

Explanation: Ambulation or walking encourages movement in the intestines, aiding in the passage of gas. It also promotes overall bowel function and can help prevent postoperative complications like atelectasis and deep vein thrombosis.
D. Use a straw.

Explanation: Using a straw doesn't have a direct impact on relieving abdominal distension or flatus. It's more relevant for patients who might have difficulty drinking directly from a glass due to medical conditions or after certain types of surgeries

A. Perform leg exercises every 2 hr. B. Irrigate the nasogastric tube every 4 to 8 hr. C. Maintain bed rest for 48 hr following surgery. D. Encourage hourly use of an incentive spirometer while awake. E. Document the color, consistency, and amount of nasogastric drainage.

Correct Answer is ["A","D","E"]

Explanation

A. Perform leg exercises every 2 hr:
After surgery, especially abdominal surgery, patients are at risk of developing deep vein thrombosis (DVT) due to decreased mobility. Performing leg exercises every 2 hours helps in improving blood circulation and preventing blood clots in the legs.

B. Irrigate the nasogastric tube every 4 to 8 hr:
Irrigating the nasogastric tube (inserting fluid into the tube) at regular intervals is not a standard practice. Nasogastric tubes are primarily used for decompression (removing stomach contents) or drainage, not for irrigation. Inserting fluids without a specific medical reason can disrupt the balance in the gastrointestinal tract and lead to complications.

C. Maintain bed rest for 48 hr following surgery:
Encouraging early mobility is a standard practice after surgery. Prolonged bed rest increases the risk of complications such as pneumonia, blood clots, and muscle weakness. Patients are typically encouraged to start moving and walking around as soon as it's safe to do so, usually within a few hours to a day after surgery, depending on the type of surgery and the patient's overall condition.

D. Encourage hourly use of an incentive spirometer while awake:
An incentive spirometer is a medical device used to help patients improve the functioning of their lungs. It encourages patients to take slow, deep breaths, which helps in expanding the lungs and preventing atelectasis (partial lung collapse) that can occur after surgery when patients may not be taking deep breaths as usual.

E. Document the color, consistency, and amount of nasogastric drainage:
Monitoring and documenting the characteristics of nasogastric drainage is essential for assessing the patient's condition. Changes in the color, consistency, or amount of drainage can indicate various issues, including bleeding, infection, or bowel perforation. This documentation helps the healthcare team make informed decisions about the patient's care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative from abdominal surgery. The client reports discomfort from abdominal distension and flatus. Which of the following suggestions should the nurse include?

Correct Answer is C

Explanation

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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