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.
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Related Questions
Correct Answer is C
Explanation
A. Check the client for a positive Chvostek's sign.
Chvostek's sign is a clinical sign of hypocalcemia (low calcium levels), not related to the client's potassium levels. The given potassium level is low, not calcium.
B. Discontinue the TPN infusion.
While the potassium level is low, discontinuing TPN without addressing the potassium deficiency can lead to further complications. TPN can be adjusted to include potassium supplementation.
C. Request a potassium replacement.
The client's low potassium level (3.0 mEq/L) requires potassium replacement. This can be done through the TPN solution or via a separate IV infusion. This choice is correct.
D. Administer glucagon IM.
Glucagon is not used to treat low potassium levels.
Correct Answer is C
Explanation
A. "I will use caution when eating high fiber foods."Clients with an ileostomy should be cautious with high-fiber foods as they can cause blockages.
B. "I will empty my pouch when it becomes one third full."
This statement is correct. Regularly emptying the pouch prevents it from becoming too heavy and ensures comfort for the client.
C. "I will be certain to take enteric-coated medications."This statement indicates a need for further teaching. Enteric-coated medications are designed to dissolve in the intestine, but with an ileostomy, the medication may pass through the digestive system too quickly to be absorbed effectively. Clients should be advised to consult their healthcare provider about medication forms, as liquid or non-enteric-coated medications may be more appropriate.
D. "I will change my entire pouch system at least weekly."
This statement is correct. Changing the pouch system regularly helps maintain hygiene and prevents skin irritation.
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