The illustration reflects a client's upper extremity while the nurse obtains a manual blood pressure. Which electrolyte abnormality is the nurse most likely to see in the client's blood chemistry results?
Hypocalcemia
Hypokalemia
Hypophosphatemia
Hyponatremia
The Correct Answer is A
A. Hypocalcemia: Hypocalcemia can cause signs such as muscle twitching, spasms, or tetany, which could be observed in the upper extremity and might be noted during a blood pressure measurement.
B. Hypokalemia: While hypokalemia can cause muscle weakness and cramping, it is less directly associated with specific upper extremity signs compared to hypocalcemia.
C. Hypophosphatemia: This generally affects energy levels and muscle function but is less commonly associated with immediate and visible upper extremity signs.
D. Hyponatremia: This primarily affects fluid balance and mental status, and is less likely to present with specific upper extremity findings during a blood pressure check.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Review with the client and spouse when to notify the physician: Appropriate
Rationale: It is essential to inform the client and their spouse about signs and symptoms that would require notifying the physician, such as increased pain, fever, or unusual symptoms. This helps ensure the client can recognize and report any issues promptly.
Instruct the client to sign their advance directive form: Inappropriate
Rationale: Advance directive forms should be completed well before a surgical procedure and are not typically addressed at the time of discharge following a minor same-day surgery. This is not directly related to the immediate postoperative care and discharge instructions.
Discuss appropriate wound care: Appropriate
Rationale: Providing instructions on how to care for the wound is crucial for preventing infection and promoting proper healing. This information is essential for the client's recovery and should be reviewed before discharge.
Educate on activity limitations: Appropriate
Rationale: Informing the client about activity restrictions helps prevent complications and supports appropriate healing. This education is crucial for ensuring the client follows guidelines that will aid in their recovery.
Provide information about dietary restrictions: Appropriate
Rationale: Depending on the type of surgery and sedation, there may be dietary restrictions or guidelines to follow. Providing this information helps the client manage their diet appropriately after discharge.
Correct Answer is C
Explanation
A. Serum glucose of 118 mg/dL: This value is slightly above the normal range but not critically elevated; it does not typically require immediate notification to the surgeon.
B. Blood urea nitrogen (BUN) of 16 mg/dL: This BUN level is within the normal range and does not suggest an immediate concern for surgical risk.
C. Serum sodium of 130 mEq/L: A serum sodium level of 130 mEq/L indicates hyponatremia, which can lead to serious complications including neurological symptoms and should be addressed prior to surgery.
D. Serum potassium of 3.9 mEq/L: This level is within the normal range and does not require immediate action related to surgery.
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