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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Decreased systolic blood pressure: In older adults, systolic blood pressure often increases due to stiffening of the arteries rather than decreasing. This increase in systolic blood pressure is due to reduced elasticity in blood vessels, making it a common physiological change.

B) Decreased anteroposterior chest diameter: In fact, the anteroposterior chest diameter often increases with age due to changes in the rib cage and spine, such as kyphosis. An increased chest diameter is observed in older adults, not a decrease.

C) Increased cerumen thickness: As people age, cerumen (earwax) production can increase and the cerumen can become thicker and drier. This is due to changes in the ceruminous glands and can lead to more frequent earwax impaction in older adults, making it a relevant point to include in the educational program.

D) Increased saliva production: Typically, older adults experience a decrease in saliva production, not an increase. Reduced saliva production can contribute to difficulties with chewing, swallowing, and oral health.

A. Provide detailed directions for the client's expected behavioral changes. B. Request the client write down an evaluation of personal strengths. C. List alternative interpretations of the client's illogical thinking. D. Encourage the client to participate in group recreational activities to help concentration.

Correct Answer is B

Explanation

A) Provide detailed directions for the client's expected behavioral changes
Giving detailed directions may overwhelm the client, increasing anxiety. It's more effective to offer support and simple, clear guidance to reduce stress.

B) Request the client write down an evaluation of personal strengths
Encouraging the client to focus on personal strengths can boost self-esteem and resilience, helping them cope with anxiety by promoting a positive self-image and reinforcing their ability to manage stress.

C) List alternative interpretations of the client's illogical thinking
While reframing thoughts can be helpful, this approach might be too confrontational initially. It's important to build trust and allow the client to explore thoughts at their own pace.

D) Encourage the client to participate in group recreational activities to help concentration
While recreational activities can be beneficial, they may not directly address anxiety management. Individual reflection on strengths can be a more immediate way to enhance coping skills.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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