A nurse reviews an immobilized patient's laboratory results and discovers that his/her calcium lab values are abnormally high (Hypercalcemia). Which condition will the nurse monitor for most closely in this patient?
Thrombus formation
Pressure Ulcers
Renal stones
Hypostatic pneumonia
The Correct Answer is C
A) Thrombus formation:
While immobility increases the risk of thrombus formation due to stasis of blood in the veins, hypercalcemia is not directly linked to thrombus formation. However, immobility and hypercalcemia could contribute to increased clotting risk indirectly, but renal stones are a more direct concern in this situation.
B) Pressure ulcers:
Pressure ulcers are a common concern for immobilized patients due to prolonged pressure on bony prominences. However, hypercalcemia does not directly cause or increase the risk of pressure ulcers. While immobility is a risk factor for pressure ulcers, hypercalcemia is not the primary cause for concern in this case.
C) Renal stones:
Hypercalcemia (elevated calcium levels in the blood) can lead to the formation of renal stones (kidney stones), as excess calcium is often excreted in the urine, where it can crystallize and form stones. This is the most direct and significant concern for a patient with high calcium levels. Monitoring for renal stones would be the priority action for the nurse in this case.
D) Hypostatic pneumonia:
Hypostatic pneumonia occurs due to immobility, causing mucus accumulation in the lungs and subsequent infection. While immobility is a concern for pneumonia, it is not specifically linked to hypercalcemia. The nurse should be monitoring for pneumonia in any immobilized patient, but the more immediate risk related to hypercalcemia is renal stones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) When observed posteriorly, the hips and shoulders form an "S" pattern: This is not a normal finding. A normal alignment should have the shoulders and hips in a straight line when observed posteriorly. An "S" pattern could indicate issues such as scoliosis or other postural abnormalities that require further assessment.
B) When observed laterally, the spinal curves align in a reversed S pattern: This is the normal finding. The spine should form a reversed "S" curve when observed laterally. This curve includes a cervical curve (forward), a thoracic curve (backward), and a lumbar curve (forward). This curvature allows for optimal shock absorption and proper weight distribution during standing and movement.
C) The arms should be crossed over the chest or in the lap: This is not a normal finding for body alignment. Arms should be relaxed at the sides or slightly away from the body in a natural, neutral position. Crossing arms can indicate discomfort or tension, which may affect the patient’s posture.
D) The feet should be close together with toes pointed out: This is not the normal body alignment. Feet should be shoulder-width apart with toes pointing forward in a neutral position when standing. Toes pointed out may indicate abnormal posture or gait patterns, such as muscle imbalances or discomfort.
Correct Answer is ["B","C"]
Explanation
A) Emptying a urinary drainage bag for a client who has pneumonia:
Wearing protective eye equipment is not necessary for emptying a urinary drainage bag. Standard precautions for handling bodily fluids would apply, but there is no expected risk for splashes to the eyes when performing this task. Gloves and hand hygiene are essential, but eye protection is not typically required.
B) Suctioning a client's new tracheostomy tube:
When suctioning a client's tracheostomy tube, there is a significant risk of splashing or spraying bodily fluids, including mucus, that may contain infectious particles. Wearing protective eye equipment is necessary to prevent potential contamination of the eyes from bodily fluids during this procedure. This is a high-risk task for exposure.
C) Irrigating a client's abdominal wound:
Irrigating an abdominal wound carries a risk of splashing bodily fluids, particularly when fluids are under pressure or if the wound is large. To avoid exposure to infectious material, the nurse should wear protective eye equipment to prevent any risk of fluids coming into contact with the eyes.
D) Providing hygiene care to a client who is HIV-positive:
Providing hygiene care to a client who is HIV-positive does not pose a significant risk to the nurse’s eyes, as HIV is transmitted through blood and certain body fluids under specific conditions. While gloves and other precautions are necessary, protective eye equipment is not required for standard hygiene care unless there is a specific risk of splashing.
E) Transporting a cerebrospinal fluid specimen to the laboratory:
When transporting cerebrospinal fluid (CSF), the primary concern is ensuring the specimen is properly contained to prevent leaks or spills. While gloves should be worn to handle the specimen, there is no direct risk of exposure to the eyes unless there is a spill. In such a case, the nurse would need to protect their eyes, but wearing protective eyewear during transport is not routinely required.
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