A nurse is caring for a client who has hypocalcemia. Which of the following findings should the nurse expect?

Muscle flaccidity

Lethargy

Constipation

Positive Chvostek's sign

Answer and Explanation

The Correct Answer is D

A. Muscle flaccidity: Hypocalcemia typically causes muscle twitching or spasms, not flaccidity. Muscle flaccidity is more often associated with conditions like hyperkalemia or electrolyte imbalances affecting muscle tone in different ways.

B. Lethargy: Lethargy can occur in various conditions, but it is not a hallmark of hypocalcemia. Instead, hypocalcemia usually causes symptoms like irritability, confusion, and muscle cramps rather than general lethargy.

C. Constipation: Constipation is more commonly associated with hypercalcemia, not hypocalcemia. Low calcium levels tend to cause neuromuscular and cardiac symptoms rather than gastrointestinal issues like constipation.

D. Positive Chvostek's sign: A positive Chvostek's sign, which is a twitching of the facial muscles when tapping the facial nerve, is a classic sign of hypocalcemia. It indicates increased neuromuscular excitability, which is characteristic of low calcium levels.

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Correct Answer is A

Explanation

A. Urine output 25 mL/hr: Urine output less than 30 mL/hr is considered inadequate, especially after surgery. This could indicate possible renal insufficiency or hypovolemia, requiring immediate attention.

B. Heart rate 68/min: A heart rate of 68/min falls within the normal adult range (60-100 beats per minute). This finding is generally considered stable and does not typically indicate an immediate complication requiring urgent reporting to the provider in a postoperative client.

C. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period, especially after abdominal surgery. This occurs due to the effects of anesthesia and bowel manipulation.

D. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is typical in the early postoperative period and usually decreases over time. It’s not abnormal unless the amount increases significantly or the drainage becomes purulent.

A. Provide a mask for the client when they are outside their room. B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. C. Don a gown when entering the client's room. D. When removing personal protective equipment, remove gloves first. E. Place the client in a room with positive air flow.

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

Explanation

A. Provide a mask for the client when they are outside their room: The client has a positive influenza test, it is important to prevent the spread of the virus to others by wearing a mask when outside their room to minimize the risk of transmission through respiratory droplets.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. While hand sanitizer is appropriate for influenza, droplet precautions, the client also has Clostridium difficile, which requires contact precautions, specifically hand hygiene with soap and water. Alcohol-based hand sanitizers are not effective against C. diff spores.

C. Don a gown when entering the client's room: The client is positive for C. difficile, which requires contact precautions. Wearing a gown when entering the room is necessary to protect healthcare workers from coming into contact with potentially contaminated surfaces or materials.

D. When removing personal protective equipment, remove gloves first: When removing personal protective equipment gloves should be removed first to avoid contamination of other surfaces. This is the recommended sequence for safe removal of PPE in contact precautions.

E. Place the client in a room with positive air flow: A room with positive air flow is necessary for airborne precautions (e.g., for tuberculosis or varicella), but it is not required for C. difficile or influenza, which are both managed through contact and droplet precautions.

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A nurse is caring for a client who has hypocalcemia. Which of the following findings should the nurse expect?

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