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A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?

A.

Initiate continuous cardiac monitoring.

B.

Administer 40 mEq/L potassium chloride PO with orange juice.

C.

Provide a diet rich in legumes, nuts, and green vegetables.

D.

Monitor the client for tetany.

Answer and Explanation

The Correct Answer is A

- A. Correct. The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia. 

- B. Incorrect. The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level. 

- C. Incorrect. The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level. 

- D. Incorrect. The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs
 


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Related Questions

Correct Answer is C

Explanation

- A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP. -

B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.

- C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.

- D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.

Correct Answer is C

Explanation

  • A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.
  • B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.
  • C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.
  • D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

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