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 ["A","B","C","D"]
Explanation
A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.
Correct Answer is C
Explanation
A. While monitoring cardiac output can provide insights into heart function, it does not directly determine the presence of dysrhythmias.
B. Peripheral extremity circulation is influenced by cardiac output but is not the primary focus of monitoring it.
C. Cardiac output is essential for determining the heart's ability to meet the body's oxygenation requirements; low cardiac output can lead to inadequate oxygen delivery.
D. Ventilation status refers to the respiratory function and is not directly assessed through cardiac output measurements.