A nurse is planning to administer the first dose of iron dextran intermittent IV bolus for a client who has iron-deficiency anemia. Which of the following interventions should the nurse plan to take?
Give a 25-mg test dose of the medication.
Flush the IV site with 3 mL of heparin following infusion.
Instruct the client to remain supine for 10 min after administration.
Dilute the medication in sterile water for injection.
The Correct Answer is D
A) Drowsiness: While drowsiness can be a sign of elevated magnesium levels, it is less critical compared to more immediate symptoms like bradycardia. Monitoring and managing drowsiness is important, but bradycardia poses a more immediate risk of severe cardiovascular issues.
B) Diminished patellar reflexes: Diminished reflexes can indicate elevated magnesium levels, but this finding is less urgent compared to symptoms directly affecting heart function. It still needs to be reported but is not the highest priority.
C) Generalized muscle weakness: Muscle weakness is another common sign of high magnesium levels, reflecting the effect of magnesium on neuromuscular function. However, it is less critical compared to bradycardia, which can be life-threatening.
D) Bradycardia: Elevated magnesium levels can significantly impact cardiac function, leading to bradycardia. Bradycardia can be life-threatening, as it may result in decreased cardiac output and potential for severe complications. Therefore, this finding requires immediate attention and should be reported to the provider first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Provide instruction on pelvic muscle exercises:
Pelvic muscle exercises are beneficial for urinary incontinence but are not a standard intervention for treating pyelonephritis. Pyelonephritis focuses on managing infection and inflammation of the kidneys rather than strengthening pelvic muscles.
B) Administer skeletal muscle relaxants every 6 hr:
Skeletal muscle relaxants are not typically used in the treatment of pyelonephritis. The focus should be on antibiotics to treat the infection and analgesics for pain relief, rather than muscle relaxants.
C) Encourage fluid intake:
Increasing fluid intake helps flush bacteria from the urinary tract, which can aid in reducing the infection and promoting kidney health. Proper hydration is crucial for clients with pyelonephritis to help manage symptoms and prevent further complications.
D) Monitor vital signs every 8 hr:
While monitoring vital signs is important, it should be done more frequently than every 8 hours, especially in the acute phase of pyelonephritis, to promptly identify any signs of worsening infection or sepsis.
Correct Answer is B
Explanation
A) "Suggest the client avoid snacking during the day.": Snacking can help maintain caloric intake and prevent malnutrition. It is generally beneficial for clients with wasting syndrome to have frequent, small meals and snacks throughout the day to increase overall caloric and nutrient intake.
B) "Encourage the client to rest before eating meals.": Resting before meals can help conserve energy, making it easier for clients with wasting syndrome to eat larger portions and improve their nutritional intake. Fatigue can significantly reduce appetite and meal consumption, so conserving energy for eating is a practical strategy.
C) "Instruct the client to consume 1 L of fluid daily.": Proper hydration is important, but 1 liter may be insufficient for overall hydration needs. Clients with AIDS and wasting syndrome should be encouraged to maintain adequate fluid intake to support overall health and aid in digestion, which typically requires more than 1 liter per day.
D) "Tell the client to increase the saturated fat content of each meal.": Increasing saturated fat content is not advisable as it can lead to other health complications such as cardiovascular disease. Instead, a balanced diet with healthy fats, proteins, and carbohydrates is more appropriate to address malnutrition in clients with wasting syndrome.
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