While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

Provide oxygen at 2 L per nasal cannula.

Provide a urinal and encourage the patient to void.

Place the patient in a high Fowler position.

Lay the patient flat in bed to listen to bowel sounds.

Answer and Explanation

The Correct Answer is C

A. Provide oxygen at 2 L per nasal cannula: Although oxygen might be helpful later, the patient currently has a good oxygen saturation (95%). The priority is to ease breathing and reduce fluid accumulation in the lungs.

B. Provide a urinal and encourage the patient to void: While voiding might help reduce fluid volume, repositioning the patient to improve breathing is more urgent.

C. Place the patient in a high Fowler position: This position maximizes lung expansion, improves oxygenation, and helps alleviate dyspnea caused by fluid overload.

D. Lay the patient flat in bed to listen to bowel sounds: Placing the patient flat can worsen pulmonary symptoms by allowing fluid to shift toward the lungs.

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Correct Answer is A

Explanation

A. Tap the face just below and in front of the ear: This is the correct technique for eliciting Chvostek’s sign, which involves tapping over the facial nerve. A positive sign (twitching of facial muscles) indicates hypocalcemia.

B. Inflate a blood pressure cuff around the upper arm for 4 minutes: This describes Trousseau’s sign, another test for hypocalcemia, where carpopedal spasm occurs due to ischemia.

C. Apply pressure over the ulnar and radial arteries: This describes Allen’s test, used to assess arterial blood flow, not calcium levels.

D. Forcefully dorsiflex the ankle when the knee is in an extended position: This describes Homan’s sign, which is used to assess for deep vein thrombosis (DVT), not hypocalcemia.

A. Increased appetite B. Hyporeflexia C. Constipation D. Headache

Correct Answer is D

Explanation

A. Increased appetite: Hyponatremia does not typically cause increased appetite.

B. Hyporeflexia: Severe hyponatremia may lead to neurological symptoms, but reflex changes are less common.

C. Constipation: This is unrelated to sodium levels.

D. Headache: Hyponatremia causes cellular swelling, including in the brain, leading to headache, nausea, and neurological symptoms.

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While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using Chvostek sign to assess for hypocalcemia. Which statement correctly describes this test?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a sodium level of 128 mEq/L (136-145 mEq/L) Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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