A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

Prepare the client for hemodialysis.

Initiate safety precautions to protect the client from injury.

Administer to the client prescribed calcium supplement.

Assess the client for tetany.

Educate the client to avoid foods that are high in calcium.

Answer and Explanation

Correct Answer : B,C,D

A. Hemodialysis is not indicated for a low calcium level unless associated with severe renal failure or other metabolic disturbances.

B. Safety precautions are important due to the risk of fractures or injury caused by weakened bones and muscle spasms related to hypocalcemia.

C. Administering prescribed calcium supplements is a key intervention to correct hypocalcemia.

D. Tetany, a sign of severe hypocalcemia, should be assessed as it can lead to muscle cramps and spasms.

E. Educating the client to avoid foods that are high in calcium would not be appropriate, as the client requires calcium to address the low levels.

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Correct Answer is D

Explanation

A. Asking the client to swallow assesses the glossopharyngeal and vagus nerves.

B. Eliciting the gag reflex also assesses the glossopharyngeal and vagus nerves.

C. Testing visual acuity assesses the optic nerve.

D. The oculomotor nerve (cranial nerve III) controls pupillary response and eye movement, so the nurse should assess the pupillary response to light.

A. Complete an incident report. B. Assess the client. C. Notify the nurse manager. D. Call the client's provider.

Correct Answer is B

Explanation

A. Completing an incident report is important but comes after ensuring the client's safety.

B. The priority is assessing the client for any adverse reactions or complications related to the incorrect medication.

C. Notifying the nurse manager should follow after the assessment and client stabilization.

D. The provider should be notified after assessing the client and identifying any clinical concerns.

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A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client on the neurologic medical-surgical unit who was admitted for a new onset of cerebrovascular attack. The client has a medical history of hypertension and diabetes. While conducting a neurologic assessment, how should the nurse assess the oculomotor nerve?

Correct Answer is D

Explanation

While checking the client's medication administration record, it was determined the client received the wrong medication. Which action should the nurse implement first?

Correct Answer is B

Explanation

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A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

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