A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Check the client for a positive Chvostek’s sign

Discontinue the TPN infusion.

Request a potassium replace

Administer glucagon IM

Answer and Explanation

The Correct Answer is C

A. Check the client for a positive Chvostek’s sign:
Chvostek's sign is a clinical sign of hypocalcemia, not related to the given laboratory values. The symptoms include facial muscle twitching when the facial nerve (VII) is tapped. There's no indication for this assessment based on the provided information.

B. Discontinue the TPN infusion:
The glucose level is within the normal range (70-99 mg/dL). Discontinuing TPN based solely on this glucose level is not warranted.

C. Request a potassium replacement:
The potassium level is low (normal range typically 3.5-5.0 mEq/L). Given the low potassium level, the nurse should plan to request a potassium replacement. Potassium is crucial for various physiological functions, and a deficiency can lead to significant complications.

D. Administer glucagon IM:
Glucagon is used to treat hypoglycemia, but the client's glucose level is within the normal range, so administering glucagon is not indicated.

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Correct Answer is D

Explanation

A. "Do you take any recreational drugs?"

This question is related to the risk of hepatitis transmission through the sharing of needles or other drug paraphernalia. Hepatitis B and C can be transmitted through contaminated needles used for injecting drugs.
B. "Did you have a blood transfusion recently?"

This question addresses the risk of hepatitis transmission through blood transfusions. While this used to be a significant risk, modern blood screening procedures have greatly reduced this risk. However, it's still a relevant question to understand the client's medical history.
C. "Have you eaten any shellfish lately?"

This question is related to the risk of hepatitis A transmission. Hepatitis A is often transmitted through contaminated food or water. Shellfish from contaminated waters can be a source of hepatitis A infection.
D. "Have you traveled to a third world country in the past two months?"

This question is crucial because hepatitis A is often more prevalent in developing countries and can be contracted through contaminated food, water, or poor sanitation. Travel history can help identify possible exposure sources.

A. Assume position with legs and rectum lower than the stomach. B. Drink cold liquids. C. Ambulate several times a day. D. Use a straw.

Correct Answer is C

Explanation

A. Assume position with legs and rectum lower than the stomach.

Explanation: This position helps gas move through the intestines more effectively, relieving abdominal distension and promoting the passage of flatus. It's a commonly recommended position for patients experiencing discomfort due to abdominal gas.
B. Drink cold liquids.

Explanation: Drinking cold liquids might not directly help with abdominal distension and flatus. Warm liquids, on the other hand, can sometimes promote digestion and relieve gas discomfort.
C. Ambulate several times a day.

Explanation: Ambulation or walking encourages movement in the intestines, aiding in the passage of gas. It also promotes overall bowel function and can help prevent postoperative complications like atelectasis and deep vein thrombosis.
D. Use a straw.

Explanation: Using a straw doesn't have a direct impact on relieving abdominal distension or flatus. It's more relevant for patients who might have difficulty drinking directly from a glass due to medical conditions or after certain types of surgeries

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A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hepatitis A. The client asks the nurse how he might have contracted the virus. Before responding, which of the following questions should the nurse first ask the client?

Correct Answer is D

Explanation

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