A nurse is assessing a client who has received treatment for hypocalcemia. Which of the following findings indicates the treatment has been effective?
Moist mucous membranes
Negative Chvostek's sign
Weight gain
Urine output 25 mL/hr
The Correct Answer is B
A. Moist mucous membranes: While moist mucous membranes may indicate adequate hydration, they are not specific to the treatment of hypocalcemia. The goal of hypocalcemia treatment is to correct calcium levels in the body, which would be reflected by the resolution of clinical signs related to low calcium, such as Chvostek's sign.
B. Negative Chvostek's sign: Chvostek's sign is a clinical sign that suggests hypocalcemia, where tapping the facial nerve causes twitching of the facial muscles. A negative Chvostek's sign indicates that calcium levels have normalized, meaning the treatment for hypocalcemia has been effective. The absence of this sign is a reliable indicator that the treatment has corrected the calcium deficiency.
C. Weight gain: Weight gain is not a typical or direct indicator of hypocalcemia treatment success. While some treatments for hypocalcemia might impact overall metabolism, weight gain is not a specific or reliable sign of calcium normalization. The most relevant sign would be the absence of symptoms related to calcium deficiency, such as a negative Chvostek’s sign.
D. Urine output 25 mL/hr: Urine output of 25 mL/hr is below the normal threshold, which is typically at least 30 mL/hr. While urine output can be affected by various factors, it is not a reliable marker for effective treatment of hypocalcemia. Treatment success is better assessed by signs related to calcium levels, such as the negative Chvostek’s sign, rather than urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Clear-colored urine: Clear-colored urine typically indicates adequate hydration or even overhydration. In Clostridium difficile, where the client may be experiencing profuse diarrhea, clear urine would not align with fluid volume deficit. This finding suggests the kidneys are excreting diluted urine, which is not consistent with dehydration.
B. Decreased urine specific gravity: A decreased urine specific gravity reflects dilute urine and usually points to overhydration or an inability to concentrate urine. In a client with C. difficile and likely diarrhea-related fluid loss, the expected finding would be a concentrated urine with increased specific gravity, not decreased.
C. Increased hematocrit: An increased hematocrit indicates hemoconcentration, which occurs when plasma volume is reduced due to fluid loss. In the setting of Clostridium difficile infection, where fluid is lost rapidly through diarrhea, this rise in hematocrit is a classic marker of fluid volume deficit. It reflects the relative increase in red blood cells due to a lower plasma volume.
D. Hypertension: Hypertension is more commonly associated with fluid volume excess or other cardiovascular conditions. In cases of fluid volume deficit, hypotension or orthostatic hypotension is more expected due to decreased circulating blood volume. Therefore, high blood pressure would not support the diagnosis of dehydration in this context.
Correct Answer is A
Explanation
A. "I do not need a pump to administer my feedings. Bolus feedings are delivered by gravity or syringe and do not require an infusion pump. They are given intermittently over a short period of time, usually in larger volumes than continuous feedings. This method is often used in clients with intact gastric function and allows more flexibility in daily routine.
B. "I should administer the formula at a cold temperature." Administering formula at a cold temperature can cause gastric discomfort, cramping, or diarrhea. Enteral formula should be administered at room temperature to promote better tolerance and reduce gastrointestinal irritation.
C. "I should advance the rate of my feedings slowly." Advancing the rate of feedings gradually applies more to continuous or cyclic feedings when transitioning a client to full nutritional intake. In bolus feeding, the rate is usually fixed per feeding and is not increased over time unless prescribed otherwise.
D. "I will administer my feedings at a constant rate over 24 hours."Administering feedings at a constant rate over 24 hours describes continuous enteral nutrition, not bolus feeding. Bolus feeding is typically done in shorter sessions several times a day and does not involve a steady infusion over a full day.
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