Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

Choice A Reason: A BMI of 28 kg/m² is considered overweight and is a modifiable risk factor for type 2 diabetes mellitus. Weight loss through diet and exercise can reduce the risk.

Choice B Reason: An HDL level of 43 mg/dL (1.11 mmol/L) is slightly below the recommended range and is a modifiable risk factor. Increasing HDL can be achieved through lifestyle changes such as exercise and dietary adjustments.

Choice C Reason: Having a sister with type 2 diabetes mellitus is a non-modifiable risk factor as it is related to genetic predisposition.

Choice D Reason: Occupational fume exposure is generally considered unrelated to the development of type 2 diabetes mellitus.

Choice E Reason: Cannabis use is typically unrelated to type 2 diabetes mellitus, though research on its long-term metabolic effects is ongoing.

Normal Ranges:

BMI: 18.5 to 24.9 kg/m² (normal)
HDL (High-Density Lipoprotein): Greater than 45 mg/dL (Greater than 1.15 mmol/L)
LDL (Low-Density Lipoprotein): Less than 130 mg/dL (Less than 3.4 mmol/L)
Fasting Blood Glucose: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)

A. Monitoring for changes in stool color is important. B. Drinking grapefruit juice will reduce the effects of the medication. C. I should take the medication with antacids. D. If I experience any difficulty with breathing, I will report it.

Correct Answer is C

Explanation

Choice A reason: Monitoring for changes in stool color can be important when taking certain medications, but it is not specifically required for itraconazole.

Choice B reason: Drinking grapefruit juice actually increases the effects of itraconazole by inhibiting its metabolism, not reducing its effects. Therefore, patients should avoid grapefruit juice while taking itraconazole.

Choice C reason: Antacids can decrease the absorption of itraconazole, making it less effective. Patients should take itraconazole with food and an acidic drink, like cola or orange juice, but not with antacids.

Choice D reason: Reporting any difficulty with breathing is appropriate advice for any medication and does not require additional instruction.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Patient Data Exhibits Review of History, Physical, and Laboratory Results Based on the findings, indicate whether each represents a modifiable risk factor, a non-modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Correct Answer is C

Explanation

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

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?

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

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?

Patient Data Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

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.