A nurse is caring for a client who has hypomagnesemia due to chronic alcohol use disorder. Which of the following actions should the nurse take?
Administer magnesium sulfate IV.
Monitor the client's blood pressure and heart rate.
Encourage the client to increase intake of green leafy vegetables.
Prepare to administer calcium gluconate IV.
Assess the client for Chvostek's sign and Trousseau's sign.
Correct Answer : A,C,E
Choice A reason:
Administer magnesium sulfate IV. This is correct because magnesium sulfate is the treatment of choice for severe hypomagnesemia. It can rapidly increase the blood level of magnesium and correct the symptoms of deficiency.
Choice B reason:
Monitor the client's blood pressure and heart rate. This is incorrect because monitoring vital signs is not a specific intervention for hypomagnesemia. However, it is important to monitor the client for signs of hypotension and bradycardia, which can occur as adverse effects of magnesium sulfate therapy.
Choice C reason:
Encourage the client to increase intake of green leafy vegetables. This is correct because green leafy vegetables are rich sources of dietary magnesium. Increasing the intake of magnesium-rich foods can help prevent or treat mild hypomagnesemia.
Choice D reason:
Prepare to administer calcium gluconate IV. This is incorrect because calcium gluconate is not indicated for hypomagnesemia. Calcium gluconate is used to treat hypocalcemia, which can occur as a complication of hypomagnesemia. However, calcium gluconate should not be given until the magnesium level is corrected, as low magnesium can impair the response to calcium.
Choice E reason:
Assess the client for Chvostek's sign and Trousseau's sign. This is correct because Chvostek's sign and Trousseau's sign are clinical tests for neuromuscular irritability, which can occur in hypomagnesemia. Chvostek's sign is elicited by tapping the facial nerve in front of the ear and observing for facial twitching. Trousseau's sign is elicited by inflating a blood pressure cuff above the systolic pressure for 3 minutes and observing for carpal spasm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A reason:
Furosemide is a potassium-wasting diuretic that may reduce the potassium level in your blood. To counteract the loss of potassium, you should try to eat enough potassium-rich foods in your diet. Some examples of potassium-rich foods include bananas, orange juice, apricots, acorn squash, butternut squash, Hubbard squash, prunes, raisins, and bran products.
Choice B reason:
Furosemide is used to treat high blood pressure and edema by causing the kidneys to get rid of unneeded water and salt from the body into the urine. To enhance the effect of furosemide and prevent fluid retention, you should decrease intake of foods high in sodium. Some examples of sodium-rich foods include processed meats, canned soups, pickles, cheese, salted nuts, and snack foods.
Choice C reason:
Furosemide does not affect the calcium level in your blood significantly. Therefore, there is no need to increase intake of foods high in calcium when taking furosemide. However, you should still consume adequate amounts of calcium for your bone health and other functions. Some examples of calcium-rich foods include milk, yogurt, cheese, broccoli, kale, and fortified cereals.
Choice D reason:
Furosemide does not affect the protein level in your blood significantly. Therefore, there is no need to decrease intake of foods high in protein when taking furosemide. However, you should still consume moderate amounts of protein for your muscle health and other functions. Some examples of protein-rich foods include eggs, fish, poultry, meat, beans, nuts, and seeds.
Choice E reason:
Furosemide can cause dehydration and electrolyte imbalance by increasing urine output. Therefore, you should increase intake of fluids as tolerated to prevent these complications. You should drink enough water to keep your urine clear or pale yellow. You should also avoid alcohol and caffeine as they can worsen dehydration.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution, not a hypotonic one. Isotonic solutions have the same concentration of solutes as blood plasma and do not cause fluid movement across the cell membrane.
Choice B reason:
This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution, not a hypertonic one. Hypertonic solutions have a higher concentration of solutes than blood plasma and cause fluid to move out of the cells and into the vascular space.
Choice C reason:
This is correct because 0.9% sodium chloride (normal saline) is an isotonic solution that will expand the vascular space by adding fluid without changing the concentration of solutes. This is useful for patients with hyponatremia (low sodium level in the blood) who need to restore their fluid and electrolyte balance.
Choice D reason:
This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution that will expand the vascular space by adding fluid without changing the concentration of solutes. It will not have no effect on fluid movement, as it will increase the intravascular volume.
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