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 A

Explanation

A. Hand hygiene is the most important action to prevent the spread of infection before any physical examination.

B. Approaching from the left side is unnecessary unless required by specific patient needs.

C. Needles should never be recapped as this increases the risk of needlestick injuries.

D. Gloves should be worn when appropriate but should not be the first action before an examination. Hand hygiene is essential before touching the client or any instruments.

A. Pale yellow urine B. Flat neck veins C. Hypotension D. Poor skin turgor E. Bradycardia

Correct Answer is ["B","C","D"]

Explanation

A. Pale yellow urine would not be expected, as dehydration often leads to concentrated, dark urine.

B. Flat neck veins are a sign of dehydration and decreased fluid volume.

C. Hypotension is expected with dehydration due to a drop in circulating blood volume.

D. Poor skin turgor is a common indicator of dehydration as the skin loses elasticity.

E. Bradycardia is not expected; rather, tachycardia is more common in dehydration as the body tries to compensate for fluid loss.

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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

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