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ATI Capstone Proctored Comprehensive
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Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance
Hypocalcemia:
- Level: <9 mg/dL
- Risk factors: Calcium deficit, diarrhea, end-stage kidney disease, wound drainage;
alkalosis, acute pancreatitis, immobility, parathyroid removal/damage
- S&S: Tetany (most common manifestation), paresthesia of the fingers and lips, muscle
twitches,
seizure, muscle spasms, hyperactive DTRs, positive Chvostek's sign (facial twitching),
positive Trousseau's sign (hand/finger spasms with BP cuff inflation), cardiovascular
irregularities, diarrhea, abdominal cramps
- Tx: Vitamin D supplements
- Complications: Cardiac arrest
Associated manifestation of Hypocalcemia
Positive Trousseau's sign
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Associated manifestation of Hyperkalemia
ECG with tall, peaked t-waves
Associated manifestation of Hyponatremia
Bounding pulse
Associated manifestation of Hypokalemia
Hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions
should the nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek
d. Tap lightly on the client's cheek
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Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which
of the following findings are manifestations of hypocalcemia? SATA
a. Tingling in fingers
b. Poor skin turgor
c. Abdominal pain
d. Elevated temperature
e. Muscle twitching
a, c, e
Numbness and tingling in fingers and toes, abdominal cramps and diarrhea, and muscle
twitching are manifestations of hypocalcemia.
Respiratory Diagnostic Procedures: Planning Care for a Client Who Is Scheduled for a
Thoracentesis
Preprocedure:
- Percussion, auscultation, radiography, or sonography is used to locate the effusion
and needle insertion site.
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- Assist the older client to maintain still for the procedure
- Position the client sitting upright with arms and shoulders raised and supported on
pillows and/or an overbed table and with feet and legs well-supported.
- Remain stills, no coughing or talking
Intraprocedure:
- Aseptic technique
- Monitor VS, skin color, and ox sat
- Amount of fluid removed is limited to 1L at a time to prevent re-expansion pulmonary
edema
Postprocedure:
- Apply dressing over puncture site
- Assess for bleeding or drainage
- Monitor VS and respiratory status hourly for the first several hours
- Encourage deep breathe to assist with lung expansion
- Obtain a postprocedure cxr
Thoracentesis
Thoracentesis is the surgical perforation of the chest wall and pleural space with a
large-bore needle. It is performed to obtain specimens for diagnostic evaluation, instill
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