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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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Free Nursing Study Resources

Correct Answer is ["A","E"]

Explanation

Choice A reason: Allergic rhinitis is a common condition that responds well to antihistamines, which can alleviate symptoms such as sneezing, runny nose, and itching.

Choice B reason: Otitis media is an inflammation of the middle ear and is not typically treated with antihistamines.

Choice C reason: Myocarditis is an inflammation of the heart muscle and is not treated with antihistamines.

Choice D reason: Bronchitis involves inflammation of the bronchial tubes and is not primarily treated with antihistamines.

Choice E reason: Contact dermatitis, which is an allergic skin reaction, can be treated with antihistamines to relieve itching and rash.

A. Advise the client to maintain bedrest to ensure safety. B. Instruct the UAP that all clients deserve equal care. C. Determine the client's level of mobility and need for assistance. D. Assign another UAP to care for the client.

Correct Answer is C

Explanation

Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.

Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.

Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.

Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What conditions are most likely to respond to treatment with antihistamines? Select all that apply.

Correct Answer is ["A","E"]

Explanation

Correct Answer is 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.