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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 E, A, C, B, D

Explanation

E. Talk to the physician as a group in a non-confrontational manner.

This is the first and most direct approach to address any interpersonal or professional issues. It allows for open communication and the possibility to resolve the issue without escalating it further.

A. Document concerns and report them to the charge nurse.

If the initial conversation does not lead to a change in behavior, documentation provides a record of the incidents and concerns, which is essential for any further action.

C. Submit a written report to the Director of Nursing.

Reporting the issue to higher management is a step up from reporting to the charge nurse. It brings the concern to the level of administration that can take more significant actions.

B. Contact the hospital's Chief of Medical Services.

If the issue persists despite the steps taken, involving the Chief of Medical Services is appropriate as they have the authority over medical staff and can address the physician's behavior from a position of leadership.

D. File a formal complaint with the state medical board.

This is the last resort when all other internal avenues have been exhausted. It involves external authorities that can impose sanctions or take other actions to ensure professional standards are maintained.

A. Teach a family member to administer eye drops. B. Encourage deep breathing and coughing exercises. C. Provide an eye shield to be worn while sleeping. D. Obtain vital signs every 2 hours during hospitalization.

Correct Answer is C

Explanation

A. Teaching a family member to administer eye drops may be appropriate for some clients undergoing eye surgery, but it is not specifically indicated for retinal detachment repair.
B. Encouraging deep breathing and coughing exercises is important for preventing respiratory complications but is not directly related to postoperative care for retinal detachment repair.
C. Providing an eye shield to be worn while sleeping is important to protect the eye and prevent inadvertent trauma during the vulnerable postoperative period. It helps promote healing and
prevents further injury to the eye.
D. Obtaining vital signs every 2 hours during hospitalization is a general nursing intervention but is not specific to the postoperative care of a client undergoing retinal detachment repair.

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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 E, A, C, B, D

Explanation

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

Correct Answer is C

Explanation

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

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An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

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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