A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect?
Tachycardia
Diarrhea
Positive Chvostek's sign
Muscle hypotonicity
The Correct Answer is D
A. Tachycardia: Hypercalcemia is more likely to cause bradycardia (slow heart rate) due to its depressive effects on the cardiac muscle.
B. Diarrhea: Hypercalcemia typically leads to constipation, not diarrhea.
C. Positive Chvostek's sign: This is associated with hypocalcemia, not hypercalcemia.
D. Muscle hypotonicity: Hypercalcemia can lead to muscle weakness and hypotonicity due to its effects on nerve and muscle function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.
B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.
C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.
D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.
Correct Answer is C
Explanation
A. Remove the window and view the incision. Inspecting the incision through the cast window is important for monitoring for signs of infection or complications, but it is not the first priority. Ensuring the extremity has adequate circulation and function is critical initially.
B. Medicate the client for pain. Pain management is essential, especially postoperatively, but assessing the integrity and function of the affected extremity takes precedence to ensure there are no immediate complications like compromised circulation or nerve damage.
C. Perform neurovascular checks of the affected extremity. Performing neurovascular checks is the highest priority to ensure that circulation, sensation, and movement are intact. This helps identify any immediate issues with the cast or complications from surgery that could jeopardize the limb’s health.
D. Turn the client so the cast will dry on all sides. Ensuring the cast dries properly is important to maintain its integrity and effectiveness, but this action is secondary to assessing neurovascular status to prevent serious complications.
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