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A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
- A. Encourage oral fluid intake.
- B. Connect the client to a cardiac monitor.
- C. Assess urinary output.
- D. Administer oral calcitonin (Calcimar).
Correct Answer: A
Rationale: The correct answer is A: Encourage oral fluid intake. When a client has hypercalcemia (serum calcium level of 14 mg/dL), the priority is to increase fluid intake to promote renal calcium excretion. This helps prevent complications such as renal calculi. The first step is to dilute the serum calcium by increasing fluid intake, which can help lower the serum calcium level. Connecting the client to a cardiac monitor (B) is not the priority as hypercalcemia affects the kidneys more than the heart. Assessing urinary output (C) is important but encouraging fluid intake is more immediate. Administering oral calcitonin (Calcimar) (D) is not the first action as it is a medication used for long-term management of hypercalcemia, not the immediate priority.
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You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a
thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that
she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance
should you first suspect?
- A. Hypophosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Hypocalcemia. Following a thyroidectomy, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. Symptoms such as tingling in lips and fingers, muscle spasms, and increased muscle tone are classic signs of hypocalcemia. The initial concern should be hypocalcemia due to its potential to cause serious complications such as tetany and laryngospasm. Options A, C, and D are incorrect as they do not align with the symptoms described. Hypophosphatemia may present with weakness and respiratory failure, hypermagnesemia with hypotension and respiratory depression, and hyperkalemia with muscle weakness and cardiac arrhythmias.
The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a
diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?
- A. Cimetidine
- B. Maalox
- C. Potassium chloride elixir
- D. ) Furosemide
Correct Answer: A
Rationale: The correct answer is A: Cimetidine. In metabolic alkalosis, the blood pH is elevated due to excess bicarbonate. Cimetidine is a histamine-2 receptor antagonist that can help decrease gastric acid production, which can contribute to alkalosis. Maalox (B) is an antacid used to treat acid-related conditions, not alkalosis. Potassium chloride elixir (C) is used to correct potassium imbalances, not directly related to alkalosis. Furosemide (D) is a loop diuretic used to treat fluid retention and edema, not specifically indicated for metabolic alkalosis.
The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining
of having trouble breathing with abdominal pain. An ABG reveals the following results: pH
7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Mixed acidbase disorder
Correct Answer: D
Rationale: The correct answer is D: Mixed acid-base disorder. The ABG results show a pH within the acidic range (7.28), indicating acidosis. The PaCO2 is elevated (50 mm Hg), suggesting respiratory acidosis as the primary disorder. However, the HCO3 level is within normal range (23 mEq/L), which is not consistent with compensatory metabolic alkalosis. Therefore, the presence of both respiratory acidosis and normal HCO3 levels indicates a mixed acid-base disorder.
Choice A (Respiratory acidosis) is incorrect because although the patient has an elevated PaCO2, the normal HCO3 level rules out a pure respiratory acidosis. Choice B (Metabolic alkalosis) and C (Respiratory alkalosis) are incorrect as the ABG results do not support these diagnoses.
The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What
should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
- A. Choose a hairless site if available.
- B. Consider potential effects on the patients mobility when selecting a site.
- C. Have the patient briefly hold his arm over his head before insertion
- D. Leave the tourniquet on for at least 3 minutes.
Correct Answer: B
Rationale: The correct answer is B because considering potential effects on the patient's mobility is crucial when selecting a site for IV insertion. Mobility can be affected if the IV is placed in a joint area or on the dominant hand. This could limit the patient's ability to move freely during and after the procedure. Therefore, it is important to choose a site that will not hinder the patient's movement.
A: Choosing a hairless site is not the most important factor when selecting a site for IV insertion.
C: Having the patient hold his arm over his head before insertion is not necessary and may cause discomfort for the patient.
D: Leaving the tourniquet on for at least 3 minutes is not recommended as it can lead to complications such as venous stasis.
A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
- A. Assess the airway.
- B. Administer prescribed bronchodilators.
- C. Provide oxygen.
- D. Administer prescribed mucolytics
Correct Answer: A
Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.