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When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which?
- A. Hyperphosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct Answer: D
Rationale: The correct answer is D, Hypokalemia. Generalized weakness, muscle weakness, leg cramps, and cardiac dysrhythmias are manifestations of hypokalemia. Checking the potassium level is essential in this case. Hypocalcemia typically presents with facial muscle spasms, not the symptoms mentioned. Hypermagnesemia does not typically cause the symptoms described. It's important to note that orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are more commonly associated with hyperkalemia, not hypokalemia.
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A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
- A. Arterial blood pH is 7.32.
- B. Serum calcium is 18 mg/dL.
- C. Serum potassium is 5.1 mEq/L
- D. Arterial oxygen saturation is 91%.
Correct Answer: B
Rationale: The correct answer is B. A serum calcium level of 18 mg/dL is significantly elevated, posing a high risk for cardiac dysrhythmias. Immediate action is required to initiate cardiac monitoring and notify the healthcare provider. While the abnormalities in arterial blood pH, serum potassium, and arterial oxygen saturation also need attention, they are not as immediately life-threatening as the critically high serum calcium level. Therefore, addressing the serum calcium level takes precedence in this scenario.
The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply).
- A. Tops of the ears
- B. Bridge of the nose
- C. Around the nostrils
- D. Over the cheeks
Correct Answer: C
Rationale: The correct answer is C: 'Around the nostrils.' Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on, including around the nostrils. Choice A, 'Tops of the ears,' is incorrect as the cannula does not rest on the ears. Choice B, 'Bridge of the nose,' is incorrect because the cannula typically rests under the nose. Choice D, 'Over the cheeks,' is also incorrect as the cannula does not typically rest on the cheeks.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
- A. Increase fluids if your mouth feels dry.
- B. More fluids are needed if you feel thirsty.
- C. Drink more fluids in the late evening hours.
- D. If you feel lethargic or confused, you need more to drink.
Correct Answer: A
Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
- A. The patient is experiencing laryngeal stridor.
- B. The patient complains of generalized fatigue.
- C. The patient has not had a bowel movement for 4 days.
- D. The patient has numbness and tingling of the lips.
Correct Answer: A
Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.
After receiving change-of-shift report, which patient should the nurse assess first?
- A. Patient with a serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
- B. Patient with a serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
- C. Patient with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
- D. Patient with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
Correct Answer: C
Rationale: The correct answer is patient C with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures, which are life-threatening. Assessing and addressing this patient's condition promptly is crucial to prevent complications. Patients A, B, and D have mild electrolyte disturbances or symptoms that require attention, but they are not at immediate risk for life-threatening complications like seizures, unlike patient C.