The nurse notices an abnormal movement in the client's hand and wrist while taking their blood pressure. What action should the nurse take?
Request a neurological consult
Have another nurse take their blood pressure
Review the client's lab values.
call the healthcare provider for orders.
The Correct Answer is C
A. Request a neurological consult: This is likely a metabolic issue (hypocalcemia), not a neurological disorder.
B. Have another nurse take their blood pressure: Rechecking BP does not address the underlying cause of the abnormal movement.
C. Review the client's lab values: Carpopedal spasm (Trousseau's sign) during BP measurement suggests hypocalcemia. The nurse should check serum calcium levels to confirm.
D. Call the healthcare provider for orders: The nurse should first review lab results to provide accurate data when notifying the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chloride level would be decreased: Metabolic alkalosis is often associated with hypochloremia, especially when caused by vomiting or diuretics. However, hypokalemia is more clinically significant.
B. Sodium level would be elevated: Sodium levels are not directly affected by metabolic alkalosis.
C. Magnesium level would be elevated: Magnesium levels are not significantly altered in metabolic alkalosis.
D. Potassium level would be decreased: A bicarbonate level of 30 mEq/L indicates metabolic alkalosis. In alkalosis, hydrogen ions shift out of the cells, and potassium moves into the cells, leading to hypokalemia.
Correct Answer is C
Explanation
A. Request a neurological consult: This is likely a metabolic issue (hypocalcemia), not a neurological disorder.
B. Have another nurse take their blood pressure: Rechecking BP does not address the underlying cause of the abnormal movement.
C. Review the client's lab values: Carpopedal spasm (Trousseau's sign) during BP measurement suggests hypocalcemia. The nurse should check serum calcium levels to confirm.
D. Call the healthcare provider for orders: The nurse should first review lab results to provide accurate data when notifying the provider.
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