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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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Correct Answer is A

Explanation

A. Redness and swelling of the calf are classic signs of deep vein thrombosis (DVT), especially in an older adult who is immobile. DVT is a common complication in hospitalized patients, particularly those who are immobile or have other risk factors such as dehydration.
B. Fat emboli typically present with symptoms such as dyspnea, tachypnea, and petechial rash, rather than localized redness and swelling of the calf.
C. Pulmonary embolism typically presents with symptoms such as chest pain, dyspnea, tachypnea, and hemoptysis, rather than localized redness and swelling of the calf.
D. While infection can cause localized redness and swelling, the presence of dehydration and immobility increases the likelihood of a thrombotic event such as deep vein thrombosis. It is important to consider DVT as a potential cause of these findings and initiate appropriate diagnostic and preventive measures.

A. Assist the client to recall everyone possibly exposed since onset of symptoms. B. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. C. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. D. Move the client to a private room, keep the door closed, and initiate droplet precautions.

Correct Answer is D

Explanation

A. Assisting the client to recall everyone possibly exposed since the onset of symptoms is important for contact tracing but is not the most immediate action to take.
B. Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is important for infection control but does not address the immediate need to prevent
potential transmission to others in the clinic setting.
C. Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is appropriate for specimen handling but does not address the need for immediate infection control measures for the client and others in the clinic setting.
D. Moving the client to a private room, keeping the door closed, and initiating droplet precautions is the most important action to take to prevent potential transmission of COVID-19 to others in the clinic setting, given the client's symptoms and recent travel history.

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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

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Naxlex Comprehensive Predictor Exams

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

Correct Answer is A

Explanation

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?

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