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 B

Explanation

A. "I will take the medication for diarrhea."
This statement is incorrect. Docusate sodium is not used to treat diarrhea; it is a stool softener used to relieve constipation.

B. "I will have soft stools 1 to 3 days after starting this medication."

This statement indicates that the client understands the purpose of docusate sodium, which is a stool softener used to prevent constipation and to soften stool. It typically takes 1 to 3 days for the medication to produce the desired effect of softer stools.

C. "I will drink one half glass of water when I take the medication."
This statement is partially correct. Taking docusate sodium with a full glass of water is recommended, not half a glass, to ensure that the medication is properly absorbed and to prevent throat irritation.

D. "I can take this medication with mineral oil."
This statement is incorrect. Docusate sodium should not be taken with mineral oil because it can increase the absorption of mineral oil, leading to systemic effects.

A. Avoid replacing the NG tube if it is accidentally dislodged. B. Irrigate the blue pigtail port with sterile saline. C. Verify tube placement by injecting air into the larger lumen. D. Avoid the nares when providing hygiene care.

Correct Answer is A

Explanation

A. Avoid replacing the NG tube if it is accidentally dislodged:After a gastrectomy, improper placement or reinsertion of the NG tube can disrupt the surgical site, leading to complications such as bleeding, leakage, or perforation. If the tube is accidentally dislodged, the nurse should notify the surgeon or provider, as reinsertions in postoperative gastric surgery clients are typically performed under their direction.

B. Irrigate the blue pigtail port with sterile saline:The blue pigtail port (air vent) of a double-lumen NG tube (e.g., Salem sump) should not be irrigated with saline because it functions as an air vent to prevent suction from damaging the stomach lining.

C. Verify tube placement by injecting air into the larger lumen:Injecting air to verify NG tube placement is no longer considered a reliable or evidence-based practice. Placement should be verified by other methods, such as aspiration of gastric contents, pH testing, or radiographic confirmation, especially in postoperative clients.

D. Avoid the nares when providing hygiene care:Hygiene care for the nares is essential to prevent skin breakdown and discomfort in clients with an NG tube. Neglecting the nares could lead to excoriation, pressure injuries, or infection.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

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