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 C
Explanation
Choice A reason: Peas are not a good choice for a mechanical soft diet, as they are small and round and can pose a choking hazard. Peas also require some chewing to break them down, which may be difficult for the client.
Choice B reason: Dried apricots are not a good choice for a mechanical soft diet, as they are hard and sticky and can damage the teeth or dentures. Dried apricots also require a lot of chewing to swallow them, which may be painful or tiring for the client.
Choice C reason: Canned pears are a good choice for a mechanical soft diet, as they are soft and moist and can be easily mashed with a fork. Canned pears do not require much chewing and can be swallowed smoothly.
Choice D reason: Cashews are not a good choice for a mechanical soft diet, as they are hard and crunchy and can injure the gums or oral mucosa. Cashews also require a lot of chewing and can get stuck in the teeth or dentures.
Correct Answer is A
Explanation
Choice A reason: Positioning the newborn at a 20-degree angle after feeding can help prevent the reflux of gastric contents into the esophagus. This position allows gravity to keep the food in the stomach and reduces the pressure on the lower esophageal sphincter. The nurse should instruct the parent to keep the newborn in this position for at least 30 minutes after each feeding.
Choice B reason: Diluting formula with 1 tablespoon of water is not recommended, as it can cause water intoxication, electrolyte imbalance, and malnutrition in the newborn. Water intoxication can lead to seizures, coma, and death. The nurse should advise the parent to follow the manufacturer's instructions for preparing the formula and not to add extra water.
Choice C reason: Placing the newborn in a side-lying position if vomiting is not a safe practice, as it can increase the risk of aspiration and sudden infant death syndrome (SIDS). Aspiration is when food or liquid enters the lungs and causes pneumonia or respiratory distress. SIDS is when a healthy baby dies suddenly and unexpectedly during sleep. The nurse should instruct the parent to place the newborn on the back for sleeping and to avoid soft bedding, pillows, and stuffed animals.
Choice D reason: Providing a small feeding just before bedtime is not a good idea, as it can worsen the gastroesophageal reflux and disrupt the newborn's sleep. The nurse should suggest the parent to feed the newborn smaller and more frequent meals throughout the day and to avoid feeding the newborn within 2 to 3 hours of bedtime.
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