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Exhibits

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

Prepare to prevent respiratory or cardiac arrest

Stop infusion of magnesium

Increase IV fluids

Obtain serum magnesium level

Administer oxygen

Obtain blood pressure

Administer calcium gluconate

Answer and Explanation

Correct Answer : A,B,D,E,G

A.   Prepare to prevent respiratory or cardiac arrest: The client's decreased level of consciousness and respiratory rate of 10 breaths/minute indicate a potential risk for respiratory or cardiac arrest. Immediate measures to maintain airway patency and support ventilation may be necessary.
B.   Stop infusion of magnesium: The client's decreased level of consciousness and absent deep tendon reflexes (DTR) bilaterally are signs of magnesium toxicity. Stopping the infusion of magnesium sulfate is essential to prevent further complications.
C.   Increasing IV fluids is not a priority in management of magnesium toxicity.
D.   Obtain serum magnesium level: With signs of magnesium toxicity, obtaining a serum magnesium level is necessary to confirm the diagnosis and guide further management.
E.   Administer oxygen: The client's oxygen saturation of 93% on room air indicates hypoxemia.
Administering oxygen via nasal cannula to maintain oxygen saturation greater than 96% helps prevent further respiratory compromise.
F.   Obtaining blood pressure is not a priority.
G.   Administer calcium gluconate: Calcium gluconate is the antidote for magnesium toxicity.
Since the client is showing signs of magnesium toxicity (decreased level of consciousness and absent DTRs), administering calcium gluconate is necessary to counteract the effects of magnesium
H.   Caesarian delivery is not part of management for magnesium toicity.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Acknowledging the parent's emotions with a supportive statement like, "This must be a very difficult time for you," validates their feelings and encourages open communication.
B. While surgery can help manage myelomeningocele, a full recovery is not always possible, as the condition may lead to lifelong complications. This response may give false reassurance.
C. Asking why the parent feels at fault could unintentionally reinforce feelings of guilt rather than providing comfort and support.
D. While it is true that the parent did nothing wrong, this response may dismiss their feelings rather than helping them process their emotions.

A. Potential changes in employee benefits. B. Changes in job descriptions. C. Employees' job security. D. New management's expectations.

Correct Answer is C

Explanation

A. Potential changes in employee benefits are important to address, but job security is a more immediate concern for employees facing agency restructuring.
B. Changes in job descriptions may occur as part of agency restructuring, but job security is typically a more pressing concern for employees.
C. Employees' job security is the most important concern to address during agency restructuring.
Employees may feel anxious about the possibility of layoffs or job loss, so providing reassurance and clear communication about job security is essential for maintaining morale and reducing
stress.
D. New management's expectations may be relevant, but they are secondary to employees' concerns about their job security during agency restructuring. Once job security is assured, addressing new management's expectations can be addressed.

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Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Correct Answer is A

Explanation

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern?

Correct Answer is C

Explanation

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

A client at 10-weeks gestation reports a maculopapular rash on the face, fever, malaise, sore throat, and lymphadenopathy. Which laboratory result should the nurse review?

Exhibits

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply