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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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Correct Answer is C

Explanation

A. Determine the last time the client had a bowel movement: While bowel movements may affect imaging studies of the abdomen, knowing the timing of the last bowel movement is not directly related to the safety or effectiveness of an IV pyelogram.
B. Inquire if the client has taken regularly scheduled medications: While it's important to know about medications, especially if they might interfere with the test or need to be temporarily
discontinued, the presence of an allergy to shellfish is more critical for IV pyelogram preparation.
C. Ask if the client has an allergy to shellfish: IV pyelogram contrast dye contains iodine, and some clients may be allergic to iodine-containing substances, including shellfish. An allergic reaction to the contrast dye could lead to serious complications.
D. Find out if the client can lie prone for the x-ray: While positioning is important for imaging studies, it's not as critical as ensuring the client does not have an allergy to the contrast dye.

A. Rapid, irregular heart rate. B. Blood-tinged sputum. C. Elevated blood pressure. D. Swollen feet and ankles.

Correct Answer is B

Explanation

A. A rapid, irregular heart rate (e.g., atrial fibrillation) is common in mitral valve stenosis due to atrial enlargement but does not necessarily require immediate intervention unless it leads to severe symptoms like syncope or stroke.

B. Blood-tinged sputum could indicate pulmonary edema or pulmonary hypertension, both of which are serious complications of mitral valve stenosis. This finding warrants immediate intervention as it may signify acute heart failure or other critical complications requiring prompt treatment.

D. Swollen feet and ankles are common signs of fluid retention in heart failure, but they do not require immediate intervention compared to the potential complications of atrial fibrillation.

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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

A client is scheduled for an IV pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray?

Correct Answer is C

Explanation

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is B

Explanation

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

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 administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.

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Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Exhibits Review History and Physical, and laboratory results. Based on the finding, indicate whether the finding represents a modifiable risk factor, a non modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

Exhibits

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