Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 45 mq, calcium 45 mg/dL?

Light-headedness when standing up

Weak quadriceps muscles

Decreased deep tendon reflexes

Tingling of extremities

Answer and Explanation

The Correct Answer is D

A. Light-headedness when standing up:
Elevated potassium levels (hyperkalemia) can lead to muscle weakness or paralysis, cardiac dysrhythmias, and even cardiac arrest. Light-headedness when standing up is more commonly associated with orthostatic hypotension or volume depletion rather than electrolyte imbalances like hyperkalemia.

B. Weak quadriceps muscles:
Weakness in the quadriceps muscles is not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can cause muscle weakness, but it is not specific to the quadriceps.

C. Decreased deep tendon reflexes:
Decreased deep tendon reflexes are not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can lead to hyperreflexia or absent reflexes, but it is not specific to decreased deep tendon reflexes.

D. Tingling of extremities:
This is the correct answer. Hypocalcemia, indicated by the low calcium level in the scenario, can manifest with symptoms such as tingling or numbness of the extremities, muscle cramps, and tetany. Calcium plays a crucial role in nerve transmission, and low levels can lead to sensory disturbances like tingling in the extremities.

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Correct Answer is A

Explanation

A. Continue to talk to the client as if they are awake: Even though the client is unresponsive, hearing can be the last sense to diminish as death approaches. Speaking to the client in a calm and reassuring manner can provide comfort and a sense of presence, even if the client cannot respond verbally.

B. Limit the client's visitors to one at a time: While it's important to manage visitors to prevent overwhelming the client, limiting them to one at a time may not be necessary if the client's condition allows for multiple visitors and the client's wishes or cultural preferences support it.

C. Avoid touching the client: Touch can be a powerful form of communication and comfort, even for an unresponsive client. Gentle touch can convey warmth and support to both the client and their family members.

D. Whisper when talking in the client's room: Whispering may create a sense of unease or anxiety for the client or their family members. Speaking in a calm and soothing voice at a normal volume is more appropriate and can help create a peaceful environment for the client's end-of-life care.

A. "It's a good idea to help make sure your husband can sleep comfortably." B. "Why do you think your husband needs more medication when he is asleep?" C. "Next time you think he needs more medication, call me and I'll push the button." D. "Your husband should decide when more medication is needed."

Correct Answer is D

Explanation

A) "It's a good idea to help make sure your husband can sleep comfortably.":
This encourages the partner to administer medication, which can lead to overmedication and potential harm.

B) "Why do you think your husband needs more medication when he is asleep?":
This might cause the partner to feel defensive. It also does not provide the necessary education about the correct use of the PCA pump.

C) "Next time you think he needs more medication, call me and I'll push the button.":
This is inappropriate as well. It does not address the core issue that only the patient should be pressing the button to ensure safe and appropriate use of the PCA pump.

D) "Your husband should decide when more medication is needed.":
This educates the partner about the proper use of the PCA pump, emphasizing that only the patient should press the button to ensure they are receiving medication only when they feel pain. This minimizes the risk of overmedication and adverse effects.

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Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 45 mq, calcium 45 mg/dL?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at the end of life and is unresponsive. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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