Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?
Weak quadriceps muscles
Decreased deep tendon reflexes
Tingling of extremities with possible tetany
Light-headedness when standing up
The Correct Answer is C
A. Weak quadriceps muscles can occur with electrolyte imbalances, but the provided values do not indicate hypokalemia or other issues causing muscle weakness.
B. Decreased deep tendon reflexes are generally associated with elevated calcium levels or other electrolyte disturbances but are not specifically indicated by the given lab values.
C. A calcium level of 4.5 mg/dL is significantly low (normal range is typically around 8.5-10.5 mg/dL), which can lead to hypocalcemia symptoms such as tingling of the extremities and tetany due to increased neuromuscular excitability.
D. Light-headedness when standing up (orthostatic hypotension) is more related to fluid volume status or dehydration rather than directly related to the given electrolyte levels.
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Correct Answer is ["B","C","D","E","F"]
Explanation
A. This statement is incorrect; the nurse should touch only the inside of the first glove while putting it on to maintain sterility.
B. The outer glove package should be removed by tearing it open to access the gloves inside.
C. After putting on the second glove, interlocking hands helps to ensure that the gloves remain sterile.
D. Slipping fingers underneath the second glove cuff with the gloved dominant hand helps to keep the gloves sterile while donning them.
E. Laying the glove package on a clean flat surface above the waistline prevents contamination.
F. The dominant hand should be gloved first to maintain a sterile technique, as the dominant hand is used for the procedure.
Correct Answer is B
Explanation
A. While the patient may have been in a life-threatening situation, this point is not necessarily a direct indictment of the nurse’s actions but rather a justification for performing CPR.
B. The prosecution will likely focus on whether the CPR was performed according to accepted standards of care. If it can be shown that the technique was inappropriate or negligent, this would support the claim of malpractice.
C. Performing CPR according to policy may serve as a defense for the nurse, emphasizing adherence to established protocols.
D. While it is true that older adults with brittle bones may be at risk for fractures, this is a known risk of CPR, and the prosecution will aim to demonstrate specific negligence or failure in technique rather than just acknowledging inherent risks.