Exhibits
The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply
Prepare to prevent respiratory or cardiac arrest
Stop infusion of magnesium
Increase IV fluids
Obtain serum magnesium level
Administer oxygen
Obtain blood pressure
Administer calcium gluconate
Correct Answer : A,B,D,E,G
A. Prepare to prevent respiratory or cardiac arrest: The client's decreased level of consciousness and respiratory rate of 10 breaths/minute indicate a potential risk for respiratory or cardiac arrest. Immediate measures to maintain airway patency and support ventilation may be necessary.
B. Stop infusion of magnesium: The client's decreased level of consciousness and absent deep tendon reflexes (DTR) bilaterally are signs of magnesium toxicity. Stopping the infusion of magnesium sulfate is essential to prevent further complications.
C. Increasing IV fluids is not a priority in management of magnesium toxicity.
D. Obtain serum magnesium level: With signs of magnesium toxicity, obtaining a serum magnesium level is necessary to confirm the diagnosis and guide further management.
E. Administer oxygen: The client's oxygen saturation of 93% on room air indicates hypoxemia.
Administering oxygen via nasal cannula to maintain oxygen saturation greater than 96% helps prevent further respiratory compromise.
F. Obtaining blood pressure is not a priority.
G. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium toxicity.
Since the client is showing signs of magnesium toxicity (decreased level of consciousness and absent DTRs), administering calcium gluconate is necessary to counteract the effects of magnesium
H. Caesarian delivery is not part of management for magnesium toicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I can only give medical information to your child because the client is an adult.": This
response respects the client's autonomy and confidentiality as an adult and upholds legal and ethical principles regarding patient privacy.
B. "I'm sorry, but your child's medical information is none of your business.": This response is dismissive and disrespectful, violating the client's right to privacy and confidentiality.
C. "The healthcare provider will share this information with you.": While healthcare providers may share information with family members if the client consents or if it's deemed necessary for the client's care, this response does not address the legal and ethical considerations regarding patient confidentiality and autonomy.
D. "I can give you those results as soon as I get them back from the lab.": This response does not address the issue of patient confidentiality and may inadvertently disclose sensitive medical information without the client's consent.
Correct Answer is C
Explanation
A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.
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