An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm.
After confirming the presence of the spasms, which action should the nurse take?
Ask the UAP to take the blood pressure in the other arm.
Tell the UAP to use a different sphygmomanometer.
Review the client’s serum calcium level.
Administer a PRN antianxiety medication.
The Correct Answer is C
Choice A rationale
While taking the blood pressure in the other arm might avoid the spasms, it does not address the underlying cause of the spasms. Therefore, this is not the best action for the nurse to take.
Choice B rationale
Using a different sphygmomanometer would not necessarily prevent the spasms from occurring. The spasms are likely not caused by the equipment itself, but rather a physiological issue within the client.
Choice C rationale
The spasms in the client’s hand and fingers could be a sign of hypocalcemia, a condition where there is not enough calcium in the blood. One of the symptoms of hypocalcemia is muscle spasms or tetany. Therefore, reviewing the client’s serum calcium level would be an appropriate action to take.
Choice D rationale
Administering a PRN antianxiety medication would not address the underlying cause of the spasms. While anxiety can cause muscle tension and spasms, there is no indication in the scenario that anxiety is the cause of this client’s symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1: The child is receiving gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes. The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.
Step 2: We need to find the infusion pump’s regulation in mL/hour.
Step 3: Since the medication is to be infused over 30 minutes, we convert this to hours by dividing by 60. So, 30 minutes is 0.5 hours.
Step 4: The rate of infusion is then the total volume (50 mL) divided by the time in hours (0.5 hours).
Step 5: So, the infusion pump’s regulation is (50 mL ÷ 0.5 hours) = 100 mL/hour.
Correct Answer is ["6.8"]
Explanation
Step 1: Convert the client’s weight from lbs to kg. 1 kg is approximately 2.2 lbs. So, 198 lbs ÷
2.2 = 90 kg (rounded to the nearest whole number).
Step 2: Calculate the total mcg of Dopamine needed per minute. The prescription is for 2 mcg/kg/minute. So, 90 kg × 2 mcg/kg/minute = 180 mcg/minute.
Step 3: Convert the total mcg of Dopamine in the bag to mcg/mL. The bag contains 400 mg of Dopamine in 250 mL. 1 mg is equal to 1000 mcg. So, 400 mg × 1000 = 400,000 mcg. Therefore, the concentration is 400,000 mcg ÷ 250 mL = 1600 mcg/mL.
Step 4: Calculate the mL of Dopamine needed per minute. So, 180 mcg/minute ÷ 1600 mcg/mL
= 0.1125 mL/minute.
Step 5: Convert mL/minute to mL/hour. There are 60 minutes in an hour. So, 0.1125 mL/minute × 60 = 6.75 mL/hour. The IV pump should be set to deliver 6.8 mL/hour (rounded to the nearest tenth).
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