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 D

Explanation

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

A. A nephrostomy tube to a drainage bag B. An NG tube to suction C. An indwelling urinary catheter to gravity drainage D. A chest tube to water-seal drainage

Correct Answer is B

Explanation

A. A nephrostomy tube to a drainage bag:
A nephrostomy tube drains urine from the kidney to a drainage bag. While it's essential for urinary drainage, it doesn't lead to significant potassium loss, as potassium is primarily excreted through the urine.

B. An NG tube to suction:
An NG tube (Nasogastric tube) is inserted through the nose into the stomach. When connected to suction, it can remove stomach contents, including gastric acid and potassium. Excessive suctioning can lead to significant potassium loss, potentially causing hypokalemia.

C. An indwelling urinary catheter to gravity drainage:
An indwelling urinary catheter drains urine from the bladder into a drainage bag by gravity. While potassium can be found in urine, the drainage through a catheter does not cause significant potassium loss unless there are underlying kidney issues, which are not specified in this scenario.

D. A chest tube to water-seal drainage:
A chest tube removes air or fluid from the pleural space around the lungs. While chest tubes are vital for lung expansion, they don't result in significant potassium loss as they are not connected to body fluids rich in potassium, like gastric acid or urine.

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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 planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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