A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Blood pressure

Syncope

ECG

Albumin

Answer and Explanation

Correct Answer : A,B,C,D,E,F

Rationale:

A. Blood pressure: Orthostatic hypotension is evident from the drop in systolic and diastolic pressure when standing, indicating fluid and electrolyte imbalance. This may reflect volume depletion due to purging and requires monitoring to prevent fainting or falls.

B. Syncope: The client reports repeated fainting episodes, a red flag when paired with orthostatic hypotension and electrolyte disturbances. This suggests unstable cardiovascular status and raises the risk of injury or sudden cardiac events.

C. ECG: Sinus tachycardia with premature ventricular contractions indicates cardiac irritability likely due to electrolyte imbalance, especially hypokalemia. Continuous cardiac monitoring and correction of abnormalities are needed.

D. Albumin: An albumin level of 2.6 g/dL indicates significant malnutrition and protein deficiency, compromising immune function and wound healing. This also suggests a chronic issue requiring dietetic intervention and nutritional rehabilitation.

E. Potassium: Potassium at 3.0 mEq/L is dangerously low and a known contributor to cardiac arrhythmias and muscle weakness. Replenishment and close monitoring are critical to avoid complications such as cardiac arrest.

F. Sodium: Although sodium is only slightly low at 134 mEq/L, in the context of purging and poor intake, this could indicate dilutional hyponatremia. It increases seizure risk and needs assessment of fluid status and intake behaviors.

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Correct Answer is B

Explanation

Rationale:

A. Prepare an IV bolus of dextrose 5% in water: Dextrose in water does not reverse magnesium toxicity. It may be used as a fluid carrier but does not serve as an antidote or address the neuromuscular and cardiac effects of excessive magnesium.

B. Administer calcium gluconate IV: Calcium gluconate is the antidote for magnesium sulfate toxicity. It helps reverse respiratory depression, muscle weakness, and cardiac conduction delays caused by high magnesium levels, making it the immediate intervention.

C. Position the client supine: The supine position can worsen hypotension by decreasing venous return, especially in pregnant clients. Left lateral positioning is generally preferred to improve circulation to vital organs and the fetus.

D. Administer methylergonovine IM: Methylergonovine is used to treat postpartum hemorrhage, but it is contraindicated in clients with hypertension or preeclampsia due to its vasoconstrictive effects. It does not treat magnesium toxicity and could increase blood pressure dangerously.

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy. B. Suggest the client join a support group for people who have colostomies. C. Instruct the client's partner to assume care of the colostomy for the client. D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.

Correct Answer is B

Explanation

Rationale:

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing negative emotions can hinder psychological adjustment. Clients should be encouraged to express their feelings openly as part of the adaptation and coping process.

B. Suggest the client join a support group for people who have colostomies: Support groups can provide emotional reassurance, shared experiences, and practical coping strategies. Seeing others manage their stomas successfully can promote acceptance and self-confidence.

C. Instruct the client's partner to assume care of the colostomy for the client: While partner support is important, encouraging dependence may delay the client’s adjustment and self-care ability. The goal should be to promote independence and acceptance at the client’s pace.

D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: A transfer is not necessary unless the client has complex needs. Initial support, education, and emotional guidance should be provided in the current care setting.

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A nurse is caring for a client in an emergency department (ED).Exhibits Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply