A nurse is caring for a client who is a long-term alcoholic. The client presents to the emergency department with vomiting and diarrhea for several days. Which findings would the nurse expect to find in this client?

dysphagia

hypoactive deep tendon reflexes (DTR)

hypomagnesemia

positive Chvostek sign hypertension

Answer and Explanation

The Correct Answer is C

A) Dysphagia: While dysphagia (difficulty swallowing) can occur in individuals with long-term alcohol use, especially if there is coexisting neurological damage or esophageal disorders, it is not specifically associated with vomiting and diarrhea in the context of this scenario. The primary concern here involves electrolyte imbalances.

B) Hypoactive deep tendon reflexes (DTR): Hypoactive DTRs are typically associated with hypermagnesemia rather than hypomagnesemia. In this case, the client's condition is more likely to lead to electrolyte deficiencies, including hypomagnesemia, due to vomiting, diarrhea, and poor nutritional intake.

C) Hypomagnesemia: Chronic alcohol use often results in nutritional deficiencies, and vomiting and diarrhea can further exacerbate this by depleting electrolytes. Hypomagnesemia is a common finding in long-term alcoholics due to poor dietary intake, gastrointestinal losses, and renal losses. This can lead to symptoms such as muscle weakness, tremors, and altered mental status. Hypomagnesemia is particularly concerning because it can affect cardiovascular stability and neuromuscular function.

D) Positive Chvostek sign: A positive Chvostek sign is indicative of hypocalcemia, which can occur secondary to hypomagnesemia. However, it is not as directly associated with chronic alcoholism as hypomagnesemia itself. The positive Chvostek sign involves a facial muscle spasm in response to tapping the facial nerve and indicates neuromuscular irritability due to low calcium levels. While related, the primary electrolyte imbalance expected here is hypomagnesemia.

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Correct Answer is D

Explanation

A) Covering the client with a blanket:

Covering the client with a blanket may help manage chills, but it does not address the underlying cause of the symptoms. Stopping the transfusion takes precedence in ensuring patient safety.

B) Assessing the client's skin for a rash:

Assessing for a rash can help determine if an allergic reaction is occurring, but the priority is to stop the transfusion to prevent further complications and address the immediate risk.

C) Notifying the provider:

Notifying the provider is important for reporting and further management, but the immediate action should be stopping the transfusion to prevent potential adverse effects.

D) Stopping the transfusion:

Stopping the transfusion is the priority action as it addresses the immediate risk of a transfusion reaction, such as an allergic reaction or transfusion-related infection. This action helps prevent further complications and ensures the client's safety.

A. 8 hr B. 4 hr C. 6 hr D. 2 hr

Correct Answer is D

Explanation

A. 8 hr - Infusing one unit of packed red blood cells (PRBCs) over 8 hours is too long. Typically, PRBCs are infused over a shorter period to avoid complications.

B. 4 hr - Infusing PRBCs over 4 hours is still within acceptable limits, but the standard time for PRBC transfusion is usually shorter.

C. 6 hr - Infusing PRBCs over 6 hours is longer than usual. The recommended duration for infusing one unit of PRBCs is generally shorter.

D. 2 hr - The standard time to infuse one unit of PRBCs is typically between 1.5 to 2 hours. This duration helps ensure the effective delivery of red blood cells while minimizing the risk of transfusion reactions.

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﻿A nurse is caring for a client who is a long-term alcoholic. The client presents to the emergency department with vomiting and diarrhea for several days. Which findings would the nurse expect to find in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. What is the nurse's PRIORITY action to complete?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who is a long-term alcoholic. The client presents to the emergency department with vomiting and diarrhea for several days. Which findings would the nurse expect to find in this client?