Nokea
A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient’s magnesium level is 6 mg/dL. What is the nurse’s priority action?
- A. Stop the infusion of magnesium.
- B. Assess the patient’s respiratory rate.
- C. Assess the patient’s deep tendon reflexes.
- D. Notify the health care provider of the magnesium level.
Correct Answer: A
Rationale: The correct answer is A: Stop the infusion of magnesium. A magnesium level of 6 mg/dL is above the therapeutic range (4-7 mg/dL) for preeclamptic patients receiving magnesium sulfate. Continuing the infusion can lead to magnesium toxicity, causing respiratory depression, cardiac arrest, and neuromuscular blockade. Stopping the infusion is crucial to prevent further complications. Assessing the patient's respiratory rate (B) and deep tendon reflexes (C) are important, but stopping the infusion takes priority to prevent harm. Notifying the health care provider (D) is important but may delay immediate action to address the high magnesium level.
You may also like to solve these questions
A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this patients nutritional needs?
- A. Administration of parenteral feeds via a peripheral IV
- B. TPN administered via a peripherally inserted central catheter
- C. Insertion of an NG tube for administration of feeds
- D. Maintaining NPO status and IV hydration until treatment completion
Correct Answer: B
Rationale: The correct answer is B: TPN administered via a peripherally inserted central catheter. TPN provides comprehensive nutrition intravenously, bypassing the GI tract, which is important for patients unable to tolerate oral intake. A peripherally inserted central catheter allows for long-term TPN administration.
A: Administration of parenteral feeds via a peripheral IV is not ideal for long-term nutrition as it may not provide complete nutrition.
C: Insertion of an NG tube may not be feasible due to the tumor location and the patient's inability to tolerate oral intake.
D: Maintaining NPO status and IV hydration alone may lead to malnutrition over time as it does not provide adequate nutrition.
Initiate feeding.
- A. 4, 2, 1, 5, 3
- B. 2, 4, 1, 3, 5
- C. 1, 4, 2, 3, 5
- D. 2, 1, 4, 5, 3
Correct Answer: B
Rationale: The correct answer is B (2, 4, 1, 3, 5) because it follows the correct sequential order for initiating feeding. First, you need to prepare the food (2), then set up the feeding area (4), followed by inviting the person to eat (1), serving the food (3), and finally allowing them to eat (5). The other choices do not adhere to the logical sequence required for initiating feeding. Choice A and D have incorrect sequences of steps, while Choice C has steps 1 and 4 switched, which disrupts the proper order of initiating feeding.
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
- A. Drink more water to prevent further dehydration.
- B. Drink more calorie-dense fluids to increase caloric intake.
- C. Drink more milk and dairy products to decrease the risk of osteoporosis.
- D. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.
Correct Answer: A
Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.
The nurse is caring for a patient withClostridiumdifficile. Which nursing actions will have thegreatest impact in preventing the spread of the bacteria?
- A. Appropriate disposal of contaminated items in biohazard bags
- B. Monthly in-services about contact precautions
- C. Mandatory cultures on all patients
- D. Proper hand hygiene techniques
Correct Answer: D
Rationale: Correct Answer: D - Proper hand hygiene techniques
Rationale:
1. Clostridium difficile is mainly spread through contact with contaminated surfaces.
2. Proper hand hygiene is the most effective way to prevent the spread of bacteria.
3. Hand hygiene removes bacteria from hands, reducing the risk of transmission.
4. Appropriate disposal (A) is important but doesn't directly prevent spread. Monthly in-services (B) and mandatory cultures (C) are not as effective as hand hygiene in preventing transmission.
The nurse is providing nutrition education to a Korean patient using the five food groups. In doing so, what should be the focus of the teaching?
- A. Discouraging the patient’s ethnic food choices
- B. Changing the patient’s diet to a more conventional American diet
- C. Including racial and ethnic practices with food preferences of the patient
- D. Comparing the patient’s ethnic preferences with American dietary choices
Correct Answer: C
Rationale: The correct answer is C because it emphasizes cultural competence and respect for the patient's background. By including racial and ethnic practices with food preferences of the patient, the nurse can provide tailored and relevant nutrition education. This approach promotes inclusivity and acknowledges the importance of cultural traditions in dietary habits. Choices A and B are incorrect as they disregard the patient's cultural background and may lead to cultural insensitivity. Choice D is also incorrect as it focuses on comparison rather than understanding and incorporating the patient's unique cultural context. Overall, choice C aligns with patient-centered care and facilitates effective communication and trust between the nurse and the patient.