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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Changing the feeding to a continuous infusion may not improve the constipation, as it does not address the fluid deficit or the fiber content of the formula. Continuous infusion may also increase the risk of aspiration, diarrhea, and bacterial contamination¹.
Choice B reason: Increasing the amount of free water can help prevent or treat constipation by hydrating the stool and facilitating its passage. The client's fluid intake and output indicate a fluid deficit, which can contribute to constipation. The recommended fluid intake for adults is 30 to 35 mL/kg/day².
Choice C reason: Decreasing the infusion rate of feeding may worsen the constipation, as it reduces the caloric and fluid intake of the client. The infusion rate should be based on the client's nutritional needs and tolerance¹.
Choice D reason: Requesting a prescription for a diuretic is not appropriate, as it would further dehydrate the client and aggravate the constipation. Diuretics are indicated for clients with fluid overload, not fluid deficit³.
Correct Answer is B
Explanation
The correct answer is: b. Offer the client frozen bananas as a snack.
Choice A: Discourage the use of a straw
Discouraging the use of a straw is not the best intervention for a client with stomatitis following radiation therapy. While using a straw might cause some discomfort, it is not a primary concern. The focus should be on providing soothing and non-irritating foods.
Choice B: Offer the client frozen bananas as a snack
Offering the client frozen bananas as a snack is an appropriate intervention. Frozen bananas can provide a soothing effect on the inflamed oral tissues and are less likely to cause irritation compared to other foods. They are also nutritious and easy to consume, making them a suitable option for clients with stomatitis.
Choice C: Serve the client hot meals
Serving hot meals is not recommended for clients with stomatitis. Hot foods can exacerbate the discomfort and irritation in the mouth, making it more painful for the client to eat. It is better to serve foods at a moderate or cool temperature to avoid further irritation.
Choice D: Avoid serving sauces or gravies
Avoiding sauces or gravies is not the best intervention for a client with stomatitis. While some sauces or gravies might be irritating, others can be soothing and help make the food easier to swallow. The key is to choose mild and non-spicy options that do not irritate the oral tissues.
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