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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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Attempting to distract the client with general conversation can help redirect the client's focus away from the discomfort and anxiety associated with the procedure. It can help alleviate anxiety and make the experience more tolerable for the client.
B. Explaining the procedure in detail while removing the staples may increase the client's anxiety and discomfort. While education about the procedure is important, it may not be the most
effective intervention in this situation.
C. Encouraging the client to continue to verbalize the anxiety acknowledges the client's feelings but may not effectively address the anxiety or alleviate discomfort during the procedure.
D. Reassuring the client that this is a simple nursing procedure may not be sufficient to alleviate the client's anxiety. The client's perception of the procedure as distressing is valid, and additional measures may be needed to help manage the anxiety and discomfort.

A. Advise the client to maintain a voiding diary for one week. B. Obtain a urine specimen for culture and sensitivity. C. Palpate the client's suprapubic area for distention. D. Instruct in effective techniques to cleanse the glans penis.

Correct Answer is C

Explanation

A:While a voiding diary can be useful for monitoring urinary symptoms, the client’s description of urinary retention symptoms requires immediate assessment for bladder distention or obstruction, not just recording voiding patterns.

B: Obtaining a urine specimen is important if a urinary tract infection is suspected, but the symptoms described are more indicative of urinary retention, possibly due to prostate issues, which requires immediate physical assessment.
C:The client’s symptoms suggest urinary retention, which can be detected by palpating the suprapubic area for bladder distention. This is the most immediate assessment to determine if the client has retained urine in the bladder.

D: Cleansing the glans penis is important for hygiene and may prevent infections, but it does not address the underlying issue of bladder fullness and urinary retention.

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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

Correct Answer is A

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?

Correct Answer is C

Explanation

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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