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) "I should choose cold foods over warm foods.": Cold foods are not necessarily better than warm foods for someone with ulcerative colitis. The choice of temperature depends on individual tolerance, but there is no specific recommendation that cold foods are preferable. Warm, easily digestible foods can also be soothing and well-tolerated.
B) "I should follow a low-protein diet.": This is not an accurate recommendation for ulcerative colitis. Protein is essential for healing and maintaining muscle mass, especially if the client is experiencing malnutrition or weight loss due to the disease. A balanced diet with adequate protein is important for overall health.
C) "I should increase my fiber intake to 35 grams a day.": High fiber intake can be problematic for those with active ulcerative colitis as it may increase symptoms such as bloating, gas, and diarrhea. It is often recommended to limit fiber intake during flare-ups and focus on low-residue diets to reduce bowel activity.
D) "I should eat small, frequent meals throughout the day.": This is a recommended approach for managing ulcerative colitis. Small, frequent meals can help ensure adequate nutrient intake without overwhelming the digestive system, which can help manage symptoms and improve overall comfort.
Correct Answer is B
Explanation
A) Bicarbonate 26 mEq/L: A bicarbonate level of 26 mEq/L is within the normal range (22-28 mEq/L) and does not indicate metabolic acidosis, which is characteristic of diabetic ketoacidosis (DKA). In DKA, bicarbonate levels are usually decreased due to buffering of the excess acids.
B) Serum pH 7.32: A serum pH of 7.32 is indicative of acidemia, which is consistent with metabolic acidosis seen in DKA. The pH is typically lower than the normal range (7.35-7.45) in DKA due to the accumulation of ketoacids.
C) Creatinine 1.2 mg/dL: A creatinine level of 1.2 mg/dL is slightly elevated but does not specifically indicate metabolic acidosis. Elevated creatinine may suggest renal impairment but is not directly linked to the acid-base disturbance seen in DKA.
D) BUN 20 mg/dL: A blood urea nitrogen (BUN) level of 20 mg/dL is elevated and may indicate dehydration or kidney dysfunction but does not specifically diagnose the acid-base imbalance associated with DKA. In DKA, bicarbonate and pH levels are more directly affected.
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