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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Hypercalcemia: AKI is typically associated with hypocalcemia because the kidneys fail to convert vitamin D to its active form, reducing calcium absorption.

B. Elevated BUN: AKI leads to impaired renal filtration, causing elevated blood urea nitrogen (BUN) and creatinine levels due to the accumulation of nitrogenous waste.

C. Metabolic alkalosis: AKI usually causes metabolic acidosis, not alkalosis, due to the accumulation of acids (e.g., lactic acid, uremic toxins).

D. Hypokalemia: AKI commonly leads to hyperkalemia due to reduced potassium excretion.

A. During dialysis B. Give as scheduled C. After returning from dialysis D. Hold the medications for today and restart tomorrow

Correct Answer is C

Explanation

A. During dialysis: Some drugs can bind to the dialysis membrane or be removed unpredictably.

B. Give as scheduled: If given before dialysis, the drugs may be removed from circulation.

C. After returning from dialysis: Dialysis removes medications from the bloodstream. Giving medications before dialysis may result in drug loss. Oral medications should be given after dialysis to ensure proper absorption and effectiveness.

D. Hold the medications for today and restart tomorrow: Unnecessary, as the client needs their medications post-dialysis.

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The nurse notices an abnormal movement in the client's hand and wrist while taking their blood pressure. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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