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 D
Explanation
A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.
B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.
C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.
D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.
Correct Answer is "{\"xRanges\":[232.4270782470703,272.4270782470703],\"yRanges\":[382.1666450500488,422.1666450500488]}"
Explanation
To determine if the child is experiencing subcostal retractions, check the area beneath the ribcage.
D - Subcostal Area:
Subcostal retractions occur below the ribs and are a sign of respiratory distress, indicating increased effort to breathe.
Observing this area can reveal inward movement during inspiration, suggesting difficulty in breathing, often seen in asthma exacerbations.
Rationale
A - Incorrect:
This area is near the clavicle and not related to subcostal retractions.
B - Incorrect:
This is the intercostal area, which can also show retractions but is not subcostal.
C - Incorrect:
This area is too central and does not correspond with subcostal retractions.
Focusing on D allows the nurse to assess the presence of subcostal retractions effectively.
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