A nurse is caring for a client who has a serum calcium level of 14 mg/dL (Normal 9.0-10.5 mg/dL). Which provider order should the nurse implement first?

Encourage oral fluid intake.

Connect the client to a cardiac monitor.

Assess urinary output.

Administer oral calcitonin (Calcimar).

Answer and Explanation

The Correct Answer is B

A. Encourage oral fluid intake: While hydration can be important for managing hypercalcemia, it is not the first priority in this scenario. A serum calcium level of 14 mg/dL is significantly elevated, and the immediate concern is the potential effect of high calcium levels on the heart and other systems.

B. Connect the client to a cardiac monitor: Elevated calcium levels (hypercalcemia) can lead to serious cardiac complications, including arrhythmias. The immediate priority is to monitor the heart's rhythm to detect any changes or disturbances caused by the high calcium level.

C. Assess urinary output: Although monitoring urinary output is important for assessing kidney function, it is not the first action to take in response to a critically high calcium level. The immediate concern is cardiac function and the potential for life-threatening arrhythmias.

D. Administer oral calcitonin (Calcimar): The first action should be to monitor the cardiac status due to the high risk of arrhythmias associated with hypercalcemia. Other interventions, such as administering calcitonin or IV fluids, can follow once the patient’s cardiac status is stabilized.

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Correct Answer is C

Explanation

A. Assess the patients for edema in extremities: While assessing for edema can be helpful in heart failure patients, it may not be the most effective method to monitor fluid volume status in patients at risk for dehydration, as edema may not be present in early dehydration.

B. Ask the patients to record their intake and output: Recording intake and output is important for monitoring fluid balance, but it is not as reliable as daily weight measurements. Patients may not be accurate in recording intake and output, especially in acute settings.

C. Weigh the patients every morning before breakfast: Weighing patients at the same time every day provides the most accurate and reliable measure of fluid volume status. A sudden weight gain or loss can indicate fluid retention in heart failure or dehydration, making this the most effective intervention for monitoring fluid status in both conditions.

D. Measure the patients' blood pressures every 4 hours: Blood pressure monitoring can provide some insight into fluid status, but it is not as directly indicative of fluid volume as daily weights. BP changes may not be as sensitive to small fluctuations in fluid volume.

A. Client taking furosemide (Lasix) B. Anxious client who has tachypnea C. Client who is on fluid restrictions D. Client who is constipated with abdominal pain

Correct Answer is B

Explanation

A. Client taking furosemide (Lasix): Furosemide is a diuretic that primarily affects urine volume and does not directly increase insensible water loss. Insensible water loss refers to water lost through skin and respiratory routes, not through urination.

B. Anxious client who has tachypnea: Tachypnea, or rapid breathing, increases the rate of water loss through the respiratory system (insensible water loss). When breathing rapidly, the body loses more moisture in the form of vapor, making this client at greatest risk.

C. Client who is on fluid restrictions: Although fluid restrictions limit overall intake, this does not increase the risk for insensible water loss, which occurs primarily through skin and respiratory loss. Fluid restriction impacts overall fluid balance rather than insensible losses.

D. Client who is constipated with abdominal pain: Constipation and abdominal pain may contribute to some discomfort or difficulty with fluid intake, but they are not related to increased insensible water loss.

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A nurse is caring for a client who has a serum calcium level of 14 mg/dL (Normal 9.0-10.5 mg/dL). Which provider order should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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