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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. Evaluating upper and lower extremities for perfusion, pulse volume, and pitting edema is important in assessing peripheral perfusion, but the priority action in this scenario is to initiate treatment for a suspected myocardial infarction.
B. Placing an indwelling urinary catheter and instituting strict intake and output measurements is not the priority action in this scenario. The client's symptoms and history suggest a cardiac event requiring immediate intervention.
C. Administering four 81 mg aspirin tablets (324 mg total) as soon as possible is the priority action for a client presenting with chest pain suggestive of acute coronary syndrome. Aspirin helps to prevent platelet aggregation and reduce the risk of clot formation.
D. Securing client consent for coronary angiography and percutaneous coronary intervention may be necessary but is not the immediate priority. The client needs immediate treatment to alleviate symptoms and stabilize the condition.

A. Ask the client to take short, rapid breaths. B. Instruct the client in pursed lip breathing. C. Increase oxygen to three L/minute. D. Have the client breathe into a paper bag.

Correct Answer is B

Explanation

A. Ask the client to take short, rapid breaths: This can increase respiratory rate and may exacerbate the client's shortness of breath.
B. Instruct the client in pursed lip breathing: Pursed lip breathing can help improve gas exchange and reduce dyspnea by slowing down the client's respiratory rate and increasing oxygenation.
C. Increase oxygen to three L/minute: Increasing oxygen without assessing the client's oxygen saturation may lead to oxygen toxicity and is not indicated without further assessment.
D. Have the client breathe into a paper bag: This intervention is not appropriate for a client with chronic obstructive lung disease experiencing shortness of breath. It is typically used for clients experiencing hyperventilation.

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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 with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

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Correct Answer is B

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