A nurse is monitoring laboratory values for a client who is receiving hemodialysis and has a serum calcium level of 7.2 mg/dL. For which of

Hyperactive deep tendon reflexes

Hypoactive bowel sounds

Positive Chvostek's sign

Lethargy

Answer and Explanation

The Correct Answer is C

Choice A: This is incorrect because hyperactive deep tendon reflexes are not associated with low serum calcium levels. Hyperactive deep tendon reflexes can indicate hypomagnesemia, hyperthyroidism, or spinal cord injury.

Choice B: This is incorrect because hypoactive bowel sounds are not associated with low serum calcium levels. Hypoactive bowel sounds can indicate ileus, peritonitis, or opioid use.

Choice C: This is correct because positive Chvostek's sign is associated with low serum calcium levels. Positive Chvostek's sign is a facial muscle spasm that occurs when tapping on the cheek near the ear. It indicates hypocalcemia, which can be caused by hemodialysis, renal failure, or parathyroid dysfunction.

Choice D: This is incorrect because lethargy is not associated with low serum calcium levels. Lethargy can indicate hypercalcemia, dehydration, hypoglycemia, or infection.

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Correct Answer is A

Explanation

Choice A reason: Asking the client if they are having difficulty breathing is the highest priority question, as it can assess the severity of their allergic reaction to penicillin and the risk of anaphylaxis, which is a life-threatening condition that can cause airway obstruction and respiratory failure.

Choice B reason: Taking the client's heart rate is not a question, but an action that can be done after asking the client about their breathing status. The heart rate can indicate the presence of tachycardia or arrhythmia, which are signs of cardiovascular compromise due to an allergic reaction.

Choice C reason: Telling the client that they need to receive diphenhydramine is not a question, but an action that can be done after asking the client about their breathing status. Diphenhydramine is an antihistamine drug that can reduce the symptoms of an allergic reaction, such as itching, swelling, or wheezing.

Choice D reason: Asking the client if they have any allergies to medications is not a high priority question, as it can be done before administering penicillin or after stabilizing the client's condition. Knowing the client's allergy history can help prevent future adverse reactions and guide appropriate treatment choices.Question 42

A. BUN 30 mg/dL B. Sinus rhythm 95/min on a cardiac monitor C. Respiratory rate 12/min D. PTT 25 seconds

Correct Answer is A

Explanation

Choice A reason: BUN or blood urea nitrogen 30 mg/dL is above the normal range of 10 to 20 mg/dL and indicates renal impairment or dehydration, which can be caused by contrast dye used during coronary angiography or blood loss during or after the procedure. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.

Choice B reason: Sinus rhythm 95/min on a cardiac monitor is within the normal range of 60 to 100/min and does not indicate any cardiac arrhythmia or ischemia.

Choice C reason: Respiratory rate 12/min is within the normal range of 12 to 20/min and does not indicate any respiratory distress or hypoxia.

Choice D reason: PTT or partial thromboplastin time 25 seconds is within the normal range of 25 to 35 seconds and does not indicate any bleeding disorder or anticoagulant therapy.

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A nurse is monitoring laboratory values for a client who is receiving hemodialysis and has a serum calcium level of 7.2 mg/dL. For which of

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Naxlex Comprehensive Predictor Exams

A nurse administered a dose of penicillin to a client 30 min ago. The client reports dizziness and wheezes when breathing. Which of the following questions by the nurse is the highest priority?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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