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 C
Explanation
A. Diabetes mellitus
Diabetes mellitus can cause easy bruising and slow wound healing, but it is not typically associated with frequent nosebleeds.
B. Hepatitis A
Hepatitis A primarily affects the liver and does not cause frequent bruising and nosebleeds.
C. Cirrhosis
Cirrhosis, which is scarring of the liver tissue due to long-term liver damage, can lead to impaired liver function. One consequence of cirrhosis is decreased production of clotting factors, which can result in easy bruising. Additionally, the enlarged spleen in cirrhosis can lead to thrombocytopenia (low platelet count), contributing to bleeding tendencies, including nosebleeds. Cirrhosis is the most likely condition given the symptoms described.
D. Cholecystitis
Cholecystitis is inflammation of the gallbladder and is not directly associated with frequent bruising and nosebleeds.
Correct Answer is D
Explanation
A. A high protein diet: While protein is essential, there is no specific indication for a high protein diet in managing chronic cholecystitis. The focus is more on reducing fat intake.
B. A high fiber diet: While a high fiber diet is generally healthy, it is not specifically emphasized for managing chronic cholecystitis. The emphasis is on reducing fat intake.
C. A low sodium diet: Sodium restriction is important for conditions like hypertension and heart failure. While it’s good for overall health, it's not a primary focus for managing chronic cholecystitis. Again, the emphasis is on reducing fat intake to prevent gallbladder attacks.
D. A low-fat diet
This is the correct answer. A low-fat diet is often recommended for individuals with chronic cholecystitis or gallstones. A low-fat diet helps to reduce the workload on the gallbladder, as fatty foods can trigger gallbladder attacks.
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