A nurse is providing care for a client who has hypomagnesemia. Which of the following actions should the nurse take?
Check the client's deep tendon reflexes every 4 hr.
Encourage the client to consume more fiber.
Restrict the client's fluid intake to 500 mL/day.
Limit sodium-containing foods on the client's meal tray.
The Correct Answer is A
Choice A reason: Checking the client's deep tendon reflexes every 4 hr is a appropriate action for a nurse to take for a client who has hypomagnesemia. Hypomagnesemia is a low level of magnesium in the blood, which can cause neuromuscular excitability and hyperreflexia. The nurse should monitor the client's reflexes for signs of increased or decreased response, which can indicate worsening or improving hypomagnesemia.
Choice B reason: Encouraging the client to consume more fiber is not a relevant action for a nurse to take for a client who has hypomagnesemia. Fiber is beneficial for digestive health and blood glucose control, but it has no direct effect on magnesium levels. The nurse should encourage the client to consume foods that are rich in magnesium, such as green leafy vegetables, nuts, seeds, legumes, and whole grains.
Choice C reason: Restricting the client's fluid intake to 500 mL/day is not a safe or effective action for a nurse to take for a client who has hypomagnesemia. Fluid restriction can cause dehydration, electrolyte imbalance, and kidney damage, which can worsen hypomagnesemia. The nurse should maintain the client's fluid balance and monitor their urine output and specific gravity.
Choice D reason: Limiting sodium-containing foods on the client's meal tray is not a necessary action for a nurse to take for a client who has hypomagnesemia. Sodium is not directly related to magnesium levels, and limiting sodium intake can cause hyponatremia, which is a low level of sodium in the blood. The nurse should ensure that the client receives adequate sodium intake from their diet or supplements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elevating the head of the client's bed can help prevent aspiration and facilitate swallowing. The nurse should keep the client's head elevated at least 30 degrees during and after feeding, and check for signs of aspiration, such as coughing, choking, or wheezing.
Choice B reason: Using a syringe to give the client fluids is not a safe method, as it can cause the fluids to enter the airway too quickly and cause aspiration. The nurse should use a spoon or a cup to give the client fluids, and thicken them if needed to make them easier to swallow.
Choice C reason: Instructing the client to chew on the left side of their mouth is not a good idea, as the left side is paralyzed and has reduced sensation. The client may not be able to chew or feel the food on that side, and may accidentally bite their tongue or cheek. The nurse should instruct the client to chew on the right side of their mouth, which is unaffected by the stroke.
Choice D reason: Instructing the client to swallow with their head tilted back is not a good practice, as it can open the airway and allow food or liquid to enter the lungs. The nurse should instruct the client to swallow with their head tilted slightly forward, which can close the airway and direct the food or liquid to the esophagus.
Correct Answer is B
Explanation
Choice A reason: Flossing dentures is not necessary, as dentures do not have spaces between the teeth where plaque and food particles can accumulate. Flossing dentures may damage the denture material or cause it to loosen.
Choice B reason: Dentures should be cleaned with a soft material to prevent scratches or damage. A washcloth is gentle enough to clean the denture surfaces without causing harm.
Choice C reason: Wiping dentures before storing them in a dry container at night is not advisable, as it may cause the dentures to crack or warp. Dentures should be soaked in water or a denture cleanser solution overnight to keep them moist and prevent them from losing their shape.
Choice D reason: Wrapping gloved fingers with gauze to remove dentures is not a standard practice. Dentures should be removed carefully by rocking them slightly to break the seal with the gums. Using gauze is unnecessary and may not be as effective or safe for the dentures or the oral tissues.
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