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Patient Data

Exhibits

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

Prepare for a cesarean delivery

Administer calcium gluconate

Obtain blood pressure

Stop infusion of magnesium

Increase IV fluids

Administer oxygen

Obtain serum magnesium level

Make preparations to prevent cardiac arrest

Answer and Explanation

Correct Answer : B,C,F,G,H

Choice A reason: Preparing for a cesarean delivery is not indicated solely based on the information provided. The patient is at 36 weeks with moderate pre-eclampsia and there are no immediate signs of fetal distress or a need for emergency delivery based on the nurse’s notes.
Choice B reason: Administering calcium gluconate is appropriate if there are signs of magnesium sulfate toxicity, as it acts as an antidote. The patient’s decreased level of consciousness and absent DTRs may suggest magnesium toxicity, making this a correct intervention.
Choice C reason: Obtaining blood pressure is a standard and ongoing requirement for monitoring a pre-eclampsia patient, especially after noting a significant drop in blood pressure from 170/98 mm Hg to 118/78 mm Hg, which could indicate an overcorrection or other issues.
Choice D reason: Stopping the infusion of magnesium sulfate is not indicated at this time. While the patient’s decreased LOC and absent DTRs are concerning, magnesium sulfate is critical for preventing seizures in pre-eclampsia and should not be stopped without clear signs of overdose and physician consultation.
Choice E reason: Increasing IV fluids is not indicated and could be harmful. The patient already has pulmonary edema and increasing fluids could exacerbate this condition, especially in the context of pre-eclampsia where fluid management needs to be carefully balanced.
Choice F reason: Administering oxygen is correct as the patient’s oxygen saturation has dropped from 98% to 93%, and the goal is to maintain it above 96% as per the physician’s orders.
Choice G reason: Obtaining serum magnesium level is correct because it is necessary to monitor for signs of magnesium sulfate toxicity given the patient’s symptoms of decreased LOC and absent DTRs.
Choice H reason: Preparing to prevent respiratory or cardiac arrest is correct as the patient has signs that may suggest impending magnesium sulfate toxicity, which can lead to respiratory depression or cardiac arrest.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

Choice A Reason: Hypoglycemia refers to low blood sugar levels, typically below 70 mg/dL (3.9 mmol/L). The client’s fasting blood glucose level is 122 mg/dL (6.8 mmol/L), which is above the normal range, thus ruling out hypoglycemia.

Choice B Reason: Diabetes mellitus is diagnosed when the fasting blood glucose level is 126 mg/dL (7 mmol/L) or higher on two separate tests1. The client’s level is slightly below this threshold, suggesting that he does not currently have diabetes mellitus but is at risk.

Choice C Reason: Prediabetes is indicated by a fasting blood glucose level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L)1. The client’s level falls within this range, indicating that he has higher than normal blood glucose levels but not high enough to be classified as diabetes, hence prediabetes.

Choice D Reason: Gestational diabetes occurs during pregnancy and is not applicable to this male client.

Option i Reason: Fatty liver disease is not directly indicated by the laboratory results provided and is typically associated with elevated liver enzymes and imaging findings.

Option ii Reason: Occupational factors are not directly related to the fasting blood glucose levels.

Option iii Reason: Lack of insulin production is a characteristic of type 1 diabetes, which is not indicated by the client’s fasting blood glucose level alone.

Option iv Reason: Impaired glucose tolerance is a condition where blood glucose levels are higher than normal but not high enough to be classified as diabetes. It is a characteristic of prediabetes and is indicated by the client’s fasting blood glucose level.

A. Encourage the client to lie as still as possible during the assessment. B. Ask the client how often episodes of sundowning are experienced. C. Assist the client with values clarification about end-of-life care options. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

Choice A reason: Encouraging the client to lie still during the assessment is not advisable as it does not provide an accurate representation of the client's functional abilities and needs during rehabilitation.

Choice B reason: While understanding episodes of sundowning can be part of a comprehensive assessment, it is not the action the nurse should implement during a functional assessment aimed at determining the client's physical capabilities.

Choice C reason: Assisting with values clarification about end-of-life care options is important but is not the primary focus of a functional assessment in a rehabilitation setting.

Choice D reason: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.

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Patient Data 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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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

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Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

Patient Data

Exhibits

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.