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 ["A","B","E"]

Explanation

A. "I will consume less caffeine and spicy foods":
Spicy foods and caffeine can irritate the esophagus, exacerbating symptoms of hiatal hernia. Avoiding these can help in managing symptoms.

B. "I will sleep with the head of my bed elevated”:
Keeping the head elevated can prevent stomach acid from flowing back into the esophagus, reducing symptoms like heartburn. This is a helpful strategy for managing hiatal hernia.

C. "I will lie down for one half hour after meals”:
Lying down after meals can worsen symptoms because gravity can't help keep stomach acid in the stomach. Staying upright after eating helps prevent acid reflux.

D. "I will drink less fluid":There is no need to reduce fluid intake. Staying hydrated is important, and fluids do not typically contribute to hiatal hernia symptoms. However, drinking large amounts of fluid with meals should be avoided as it can increase stomach pressure.

E. "I will try not to gain weight”:
Maintaining a healthy weight is important. Excess weight can increase pressure on the abdomen, potentially worsening hiatal hernia symptoms.

A. Slight bleeding of the stoma site B. Purplish colored stoma C. No stool noted in the collection bag D. Edematous stoma

Correct Answer is B

Explanation

A. Slight bleeding of the stoma site: This is typically normal in the immediate postoperative period. It's caused by surgical trauma and should improve with time. However, if it becomes excessive, it should be reported.

B. Purplish colored stoma: A purplish or bluish color of the stoma can be an indication of inadequate blood supply (ischemia). This is a concerning finding and should be reported promptly to the provider.

C. No stool noted in the collection bag: It's normal not to have stool in the collection bag immediately after surgery since the digestive system needs time to resume normal function. This is usually not a concern within the first 12 hours postoperatively. However, if it continues beyond this time frame, it should be reported.

D. Edematous stoma: Some edema or swelling around the stoma site can be normal initially after surgery. However, if the stoma becomes significantly edematous or starts to compromise blood flow, this should be reported to the provider.

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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 reinforcing teaching about dietary recommendations for a client who has a hiatal hernia. Which of the following client statements indicate understanding of the teaching? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

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