A nurse is reviewing the laboratory values of a patient receiving total parenteral nutrition (TPN). The glucose is 72 mg/dL, chloride is 100 mEq/L, sodium is 138 mEq/L, and potassium is 3.0 mEq/L. What action should the nurse plan to take?
Administer glucagon IM.
Discontinue the TPN infusion.
Request a potassium replacement.
Check the patient for a positive Chvostek’s sign.
The Correct Answer is C
The correct answer is Choice C.
Step 1 is to interpret the laboratory values. The glucose level is within the normal range (7099 mg/dL). The chloride level is within the normal range (97-107 mEq/L). The sodium level is within the normal range (135-145 mEq/L). However, the potassium level is low (normal range is 3.5-5.0 mEq/L)89101112.
Step 2 is to plan the action based on the interpretation. Given the low potassium level, the nurse should plan to request a potassium replacement
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
Correct Answer is A
Explanation
Choice A rationale
Changing gloves between tasks on the same client is a key infection control practice. This prevents cross-contamination between different body sites and reduces the risk of spreading infection.
Choice B rationale
Washing hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile is not recommended. Clostridium difficile spores are not killed by alcohol-based hand rubs. Handwashing with soap and water is more effective.
Choice C rationale
Using alcohol-based hand rubs before administering eye drops for a client is a good practice, but it is not the most important information to reinforce. Hand hygiene is crucial in all aspects of patient care to prevent the spread of infection.
Choice D rationale
Keeping artificial nails trimmed short is a good practice, but it is not the most important information to reinforce. Artificial nails can harbor bacteria and other pathogens, increasing the risk of infection transmission.
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