The nurse notices an abnormal movement in the client's hand and wrist while taking their blood pressure. What action should the nurse take?

Request a neurological consult

Have another nurse take their blood pressure

Review the client's lab values.

call the healthcare provider for orders.

Answer and Explanation

The Correct Answer is C

A. Request a neurological consult: This is likely a metabolic issue (hypocalcemia), not a neurological disorder.

B. Have another nurse take their blood pressure: Rechecking BP does not address the underlying cause of the abnormal movement.

C. Review the client's lab values: Carpopedal spasm (Trousseau's sign) during BP measurement suggests hypocalcemia. The nurse should check serum calcium levels to confirm.

D. Call the healthcare provider for orders: The nurse should first review lab results to provide accurate data when notifying the provider.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Oliguria: Reduced urine output (oliguria) can indicate acute rejection due to decreased renal function. Other signs include fever, hypertension, graft tenderness, and swelling.

B. Temperature 36.1° C (97.0° F): Rejection often causes fever, not a low temperature.

C. Weight loss: Weight gain (fluid retention) is more common with rejection.

D. Insomnia: Insomnia is not a direct sign of rejection.

A. Serum potassium 4.8 mmol/l B. Serum glucose 58 mg/d C. Serum sodium 138 mEq/L D. Calcium level of 100 mg

Correct Answer is B

Explanation

A. Serum potassium 4.8 mmol/L: This is a normal potassium level (3.5–5.0 mmol/L) and indicates successful treatment.

B. Serum glucose 58 mg/dL: IV insulin drives potassium into cells, lowering serum potassium. However, insulin also lowers blood glucose, which can lead to hypoglycemia (glucose <70 mg/dL). Hypoglycemia is the primary adverse effect of IV insulin therapy.

C. Serum sodium 138 mEq/L: This is a normal sodium level (135–145 mEq/L) and not an adverse effect.

D. Calcium level of 100 mg: Calcium is not directly affected by IV insulin therapy.

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The nurse notices an abnormal movement in the client's hand and wrist while taking their blood pressure. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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