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 D

Explanation

A. Elevated blood pressure: Hypocalcemia is more likely to cause low blood pressure due to its effect on vascular tone and cardiac contractility, not elevated blood pressure.

B. Negative Chvostek sign: A negative Chvostek sign would be expected in clients with normal calcium levels. A positive Chvostek sign (twitching of the facial muscles when tapped) is a sign of hypocalcemia.

C. Constipation: Hypocalcemia does not typically cause constipation. In fact, hypercalcemia can lead to constipation.

D. Tetany: Tetany, which involves muscle cramps and spasms, is a common manifestation of hypocalcemia. It occurs due to increased neuromuscular excitability when calcium levels are low.

A. Skeletal muscle weakness B. Decreased deep-tendon reflexes C. Tingling of the lips D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. Skeletal muscle weakness: This is more commonly seen with hypercalcemia, not hypocalcemia. Hypocalcemia typically causes neuromuscular irritability, which manifests as muscle spasms rather than weakness.

B. Decreased deep-tendon reflexes: This is more commonly seen with hypercalcemia. Hypocalcemia typically increases neuromuscular irritability and can cause hyperactive reflexes.

C. Tingling of the lips: This is a classic sign of hypocalcemia, as low calcium levels can lead to neuromuscular excitability, which can cause sensations like tingling (paresthesia) around the lips and fingers.

D. Hypoactive bowel sounds: Hypocalcemia typically increases bowel motility, which can lead to hyperactive bowel sounds, not hypoactive bowel sounds.

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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

A nurse is collecting data from a client who has a calcium level of 8 mg/dL (9.0-10.5 mg/dL). Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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