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 C

Explanation

A. Bradycardia
Bradycardia is not a direct symptom of gastrointestinal perforation. When a perforation occurs, the body's response is often to increase the heart rate (tachycardia) due to the stress and shock.

B. Report of epigastric fullness
Epigastric fullness might be a symptom of peptic ulcer disease but is not specific to gastrointestinal perforation.

C. Severe upper abdominal pain
Correct choice. Severe upper abdominal pain, particularly sudden and intense pain, can be indicative of gastrointestinal perforation. This is a medical emergency and requires immediate attention.

D. Hyperactive bowel sounds
Gastrointestinal perforation can lead to absent or hypoactive bowel sounds due to inflammation and irritation of the abdominal cavity, not hyperactive bowel sounds.

A. Prior to percussing the abdomen B. Prior to inspecting the abdomen C. After checking int kidney tenderness D. After palpating the abdomen

Correct Answer is A

Explanation

A. Prior to percussing the abdomen
Bowel sounds are typically auscultated before performing any other abdominal assessments. This allows the nurse to get an accurate representation of the client's bowel activity without any interference from other assessment techniques.

B. Prior to inspecting the abdomen
Inspecting the abdomen involves observing for any visible abnormalities, such as distension or lesions. Bowel sounds are auscultated first to get an initial sense of the client's gastrointestinal activity.

C. After checking for kidney tenderness
Kidney tenderness assessment is not directly related to bowel sounds. These assessments are separate and do not impact each other's sequence.

D. After palpating the abdomen
Palpating the abdomen should be done after auscultation. Palpation can stimulate bowel activity, potentially altering the natural bowel sounds. Therefore, it is essential to auscultate the abdomen before palpating it.

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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

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

Correct Answer is C

Explanation

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is A

Explanation

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