A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first?
Order a lunch tray for the client.
Offer the client apple juice.
Auscultate the client's abdomen.
Elevate the client's head of bed.
The Correct Answer is C
A. Order a lunch tray for the client. Before advancing the diet, it is important to assess the client's readiness, particularly bowel sounds.
B. Offer the client apple juice. Providing liquids is appropriate only after assessing the client's gastrointestinal function.
C. Auscultate the client's abdomen: This assessment checks for the return of bowel sounds and gastrointestinal function, indicating whether the client can tolerate clear liquids.
D. Elevate the client's head of bed. While positioning is important, the primary first step is to assess the client's gastrointestinal status
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tetany: A calcium level of 8 mg/dL is below the normal range (8.5-10.5 mg/dL) and can cause tetany, which includes muscle cramps, spasms, and positive signs like Chvostek and Trousseau signs.
B. Constipation: Constipation is more commonly associated with hypercalcemia, not hypocalcemia.
C. Negative Chvostek sign: A positive Chvostek sign is expected in hypocalcemia, indicating neuromuscular irritability.
D. Elevated blood pressure: Elevated blood pressure is not specifically associated with hypocalcemia.
Correct Answer is D
Explanation
A. Decreased bowel sounds: Hypocalcemia typically causes increased neuromuscular excitability, which can lead to increased bowel sounds.
B. Dry, sticky mucous membranes: Dry, sticky mucous membranes are more indicative of dehydration or hypernatremia.
C. Hypoactive deep-tendon reflexes: Hypocalcemia usually causes hyperactive deep-tendon reflexes, not hypoactive.
D. Numbness of extremities: Numbness and tingling in the extremities are common symptoms of hypocalcemia due to increased neuromuscular excitability.
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