Family members of a client with a terminal illness tell a nurse that the client keeps asking if she is dying.
What is the nurse's highest priority response.

Choice A rationale

Magnesium sulfate administration is scientifically indicated because the patient's magnesium level is 0.2 mEq/L, which is significantly lower than the normal range of 1.5 to 2.5 mEq/L. Hypomagnesemia increases myocardial irritability and can directly precipitate premature ventricular contractions or torsades de pointes. Providing 2 grams intravenously helps stabilize the cardiac membrane potential by restoring the necessary cofactor for the sodium potassium adenosine triphosphatase pump, which maintains the appropriate intracellular and extracellular electrolyte gradients.

Choice B rationale

Increasing oxygen to 6 L/min is appropriate because the patient's SpO2 is currently 92 percent, which is at the lower limit of acceptable for a patient three days post anterior wall myocardial infarction. Normal SpO2 should ideally be ≥ 94 percent in cardiac patients to ensure adequate myocardial oxygenation. Increasing the fraction of inspired oxygen helps reduce the workload of the heart and may decrease the frequency of ectopy caused by localized areas of myocardial hypoxia.

Choice C rationale

Administering 40 mEq of potassium chloride is inappropriate for this specific patient because her potassium level is 4.4 mEq/L, which falls perfectly within the normal physiological range of 3.5 to 5.0 mEq/L. Over-supplementing potassium when the serum level is already optimal carries a significant risk of inducing hyperkalemia. Excessive potassium can lead to lethal arrhythmias, such as ventricular fibrillation or asystole, by disrupting the resting membrane potential and interfering with cardiac repolarization.

Choice D rationale

Lidocaine 100 mg IV push is a standard pharmacological intervention for a patient experiencing frequent or multifocal premature ventricular contractions following an acute myocardial infarction. Lidocaine is a Class IB antiarrhythmic that works by blocking fast voltage-gated sodium channels, particularly in ischemic tissues. This action shortens the action potential duration and raises the fibrillation threshold, thereby suppressing ventricular ectopy and preventing the progression to more dangerous rhythms like ventricular tachycardia or ventricular fibrillation.

Choice A rationale

Requesting that family members prepare the body is inappropriate and culturally insensitive in most hospital settings. While some cultures may wish to participate in the washing or dressing of the deceased, the nurse should never assume this or place the burden of postmortem care entirely on grieving relatives. The nurse is responsible for the dignified handling of the body, and the priority is first addressing the emotional needs of the family present.

Choice B rationale

Ensuring the death certificate is completed is a necessary legal and administrative step in postmortem care, but it is not the immediate priority for the nurse at the bedside. The primary focus immediately following the death should be on the psychosocial and emotional support of the family members who are currently experiencing the loss. Administrative tasks can be managed once the family has been initially supported and offered time with their loved one.

Choice C rationale

Calling for emergency assistance to begin resuscitation is inappropriate because the patient is described as terminally ill and has already died. If the patient has a Do Not Resuscitate order or is in the end stages of a terminal disease, performing CPR would be contrary to their wishes and ethically unsound. The nurse's role in this moment is to provide a peaceful environment and support the survivors, rather than initiating futile medical interventions.

Choice D rationale

The priority intervention after a death is to provide compassionate, family-centered care. Offering the family time alone with the deceased allows them to begin the grieving process and say their final goodbyes in a private, respectful environment. This supports the emotional well-being of the survivors and honors the dignity of the patient. Once the family has had this opportunity, the nurse can then proceed with the technical aspects of postmortem body care.