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 ["A","D","E"]
Explanation
A. Perform leg exercises every 2 hr: This is a good practice for any postoperative patient to prevent blood clots and maintain circulation. It's especially important for patients who might be relatively immobile due to surgery.
B. Irrigate the nasogastric tube every 4 to 8 hr: This is generally not a standard procedure. Nasogastric tubes are typically used for drainage or feeding. If there's a blockage or other issue, healthcare providers might intervene, but routine irrigation is not commonly done.
C. Maintain bed rest for 48 hr following surgery: While some rest might be necessary immediately after surgery, the trend in modern healthcare is to encourage mobility as soon as it's safe. Early mobilization can prevent complications such as blood clots and aid in recovery.
D. Encourage hourly use of an incentive spirometer while awake: Incentive spirometry is often encouraged postoperatively to prevent lung complications like atelectasis. Regular use helps keep the lungs expanded and functioning optimally.
E. Document the color, consistency, and amount of nasogastric drainage: This is crucial. Monitoring the drainage can provide important information about the patient's condition, such as bleeding or the effectiveness of the treatment. Any changes should be reported to the healthcare provider.
Correct Answer is C
Explanation
A. Oatmeal: Oatmeal is often considered a bland and low-acid food that can be soothing for individuals with GERD. It's generally not a trigger for GERD symptoms and can be included in the diet of someone with this condition.
B. Non-fat milk: Non-fat milk and other low-fat dairy products are often recommended for individuals with GERD. However, individual tolerance varies, and some people might find that milk triggers their symptoms. It's best for the patient to monitor their own reactions to dairy products.
C. Chocolate: Chocolate is known to relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus. For many people with GERD, chocolate can exacerbate symptoms and is typically advised to be avoided.
D. Apples: Apples are generally considered a safe and healthy food for individuals with GERD. However, some people may find that raw apples trigger their symptoms due to their natural acidity. Cooking or baking apples can often make them more tolerable for people with GERD.
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