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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 A

Explanation

A. A goal of maintaining a blood pressure less than 140/80 mm Hg aligns with recommended targets for clients with cardiovascular disease to reduce the risk of complications.
B. While physical activity is beneficial, stating that the nurse will encourage the client to walk is not a measurable client-centered outcome. A better outcome would focus on the client’s actions.
C. Monitoring blood glucose is more relevant for diabetes management rather than a primary outcome for cardiovascular disease.
D. A target of less than 160/90 mm Hg is too high and does not align with standard guidelines for blood pressure control in cardiovascular disease.

A. Gonorrhea. B. Group B Streptococcus. C. Toxoplasmosis. D. Rubella.

Correct Answer is D

Explanation

A. Gonorrhea: While sexually transmitted infections can affect pregnancy, the symptoms described are not consistent with gonorrhea.
B. Group B Streptococcus: Group B Streptococcus is commonly screened for in pregnant individuals but does not typically present with the described symptoms.
C. Toxoplasmosis: Toxoplasmosis can affect pregnancy, but the symptoms described are not specific to toxoplasmosis.
D. Rubella: Rubella infection during pregnancy can lead to congenital rubella syndrome, which can cause birth defects. The symptoms described are consistent with rubella infection.

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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

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Explanation

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Correct Answer is D

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