When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement?
Reference Range
lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]
Determine apical pulse rate and rhythm.
Observe color and amount of urine.
Assess strength of deep tendon reflexes.
Compare muscle strength bilaterally
The Correct Answer is A
A. An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B. While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C. Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D. Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B. While privacy is important, the spouse can often provide additional valuable information.
C. Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D. Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.
Correct Answer is B
Explanation
A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.
B.Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.
C.Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.
D.Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
