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) "Limit fluids that contain electrolytes":
For a client with gastroenteritis, it is crucial to maintain hydration due to the risk of dehydration from diarrhea and vomiting. However, fluids containing electrolytes can help replenish lost electrolytes and are beneficial. The instruction to "limit" these fluids might be misunderstood as a need to avoid them, which is not appropriate. The aim should be to encourage adequate hydration with fluids that contain electrolytes.
B) "Eliminate sources of probiotics from the diet":
Probiotics can help restore the balance of gut bacteria and may be beneficial in managing gastroenteritis. Eliminating probiotics from the diet is not typically recommended and may not support the recovery process.
C) "Take docusate sodium twice daily":
Docusate sodium is a stool softener, generally used to relieve constipation. In the context of gastroenteritis, which typically involves diarrhea, this medication is not appropriate and could worsen the condition.
D) "Avoid foods high in simple sugars":
Foods high in simple sugars can exacerbate diarrhea by increasing osmotic load in the intestines, leading to more water being drawn into the gut. Avoiding these foods can help manage and reduce symptoms of gastroenteritis.
Correct Answer is B
Explanation
A) "Suggest the client avoid snacking during the day.": Snacking can help maintain caloric intake and prevent malnutrition. It is generally beneficial for clients with wasting syndrome to have frequent, small meals and snacks throughout the day to increase overall caloric and nutrient intake.
B) "Encourage the client to rest before eating meals.": Resting before meals can help conserve energy, making it easier for clients with wasting syndrome to eat larger portions and improve their nutritional intake. Fatigue can significantly reduce appetite and meal consumption, so conserving energy for eating is a practical strategy.
C) "Instruct the client to consume 1 L of fluid daily.": Proper hydration is important, but 1 liter may be insufficient for overall hydration needs. Clients with AIDS and wasting syndrome should be encouraged to maintain adequate fluid intake to support overall health and aid in digestion, which typically requires more than 1 liter per day.
D) "Tell the client to increase the saturated fat content of each meal.": Increasing saturated fat content is not advisable as it can lead to other health complications such as cardiovascular disease. Instead, a balanced diet with healthy fats, proteins, and carbohydrates is more appropriate to address malnutrition in clients with wasting syndrome.
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