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
Explanation
A. An air vent allowing bubbles into the blood would be unsafe and can cause air embolism, so this option is incorrect.
B. Using tubing with a filter is standard practice for blood transfusions to prevent clots and debris from entering the patient’s bloodstream, making this the correct choice.
C. Mixing additional electrolytes into the blood is not a standard practice during transfusions, as it can cause complications; thus, this option is not appropriate.
D. Two-way valves are not typically used in blood transfusion setups; the goal is to keep the blood product separate from other fluids unless specifically indicated.
Correct Answer is A
Explanation
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B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.