The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:
strain all of the client's urine.
inflate a blood pressure cuff 20 mmHg above systolic measurement.
lightly percuss the client's cheek.
obtain a baseline height and weight.
The Correct Answer is C
C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.
A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.
B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.
D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Teaching preschoolers how to wash their hands correctly is an example of primary prevention. By educating children on proper hand hygiene practices, nurses aim to reduce the spread of infections and promote good health habits. This activity focuses on preventing the transmission of infectious diseases and promoting overall wellness among children
A. Screening for high blood pressure is an example of secondary prevention rather than primary prevention. Secondary prevention involves early detection and treatment to halt or slow down the progress of a disease.
C. Providing hospice care is a form of palliative care that focuses on improving the quality of life for terminally ill clients and their families. It aims to provide comfort and support rather than preventing disease onset. Therefore, it does not fall under primary prevention but rather under supportive care for those with advanced illness.
D. Teaching a client how to self-administer insulin is an example of tertiary prevention. Tertiary prevention involves managing and reducing the impact of a disease that has already occurred. In this case, teaching self-administration of insulin helps manage diabetes, prevent complications, and promote optimal health outcomes for the client.
Correct Answer is ["A","B","D"]
Explanation
A. This is the part of the IV administration set that pierces the IV bag or bottle to allow fluid to flow into the tubing. The plastic insertion spike must remain sterile because it comes into direct contact with the fluid within the IV container. Contamination of the spike could introduce microorganisms into the IV solution.
B. The catheter adapter or hub is the part of the IV administration set where the IV catheter or cannula connects. It is crucial for this part to remain sterile to prevent introducing pathogens into the bloodstream during catheter insertion or manipulation.
D. The Y-site injection port is a branching point in the IV tubing where additional medications or fluids can be infused into the IV line. It must remain sterile to prevent contamination when administering medications or secondary infusions.
C. The drip chamber is located in the IV tubing, just below the IV bag or bottle. It is designed to visualize and regulate the flow of IV fluid into the patient. It does not directly contact the bloodstream or the IV fluid inside the tubing.
E. Roller clamp to regulate flow (Option E) does not necessarily need to be sterile because it does not come into direct contact with IV fluid or the patient's bloodstream. However, it should be handled with clean hands to maintain general cleanliness and to prevent contamination of other sterile parts of the IV set.
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