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The nurse is administering IV magnesium to a client with a magnesium level of 1.5 mEq/L (0.62 mmol/L) [1.5-2.5 mEq/L, 0.6-1.2 mmol/L]. You check on them halfway through the infusion, and they report that their face feels flushed. What is the priority nursing intervention?
- A. Slow down the infusion rate.
- B. Notify the primary healthcare provider (PHCP).
- C. Reassess the client when the infusion finishes.
- D. Stop the infusion.
Correct Answer: A
Rationale: Flushing is a common side effect of IV magnesium infusion and can often be managed by slowing the infusion rate to reduce symptoms. Stopping the infusion (D) or notifying the PHCP (B) is not necessary unless symptoms worsen. Reassessing later (C) delays intervention.
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The nurse is caring for a client who has bacterial cystitis. The physician prescribes the client gentamicin. To prevent a complication associated with this medication, the nurse should monitor the client's?
- A. intake and output ratio.
- B. creatinine.
- C. visual acuity.
- D. fasting blood glucose.
Correct Answer: B
Rationale: Gentamicin, an aminoglycoside, is nephrotoxic, so monitoring creatinine is essential to detect renal impairment. Intake and output (A) are less specific, and visual acuity (C) and blood glucose (D) are not directly affected by gentamicin.
A client experiencing an acute exacerbation of ulcerative colitis underwent diagnostic testing and was found to have elevated serum osmolality and urine specific gravity. Which of the following is related to these findings?
- A. Renal insufficiency
- B. Diabetes insipidus
- C. Hypoaldosteronism
- D. Deficient fluid volume
Correct Answer: D
Rationale: Elevated serum osmolality and urine specific gravity indicate deficient fluid volume due to dehydration from colitis.
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a client following a transurethral resection of the prostate (TURP).
Item 1 of 1
Nurses’ Notes
1241: The client arrived at the medical-surgical unit six hours post-operative from a TURP. The client was alert and oriented to person, place, time, and situation. The client has a three-way indwelling urinary catheter and is continuously irrigated with isotonic saline. Urine output is ketchup-like with medium to large clots. The client reports the need to urinate and reported pressure in the pelvic region, described as spasms.
Intake and Output
Intake – Continuous bladder irrigation: 550 mL
Output – Indwelling catheter: 975 mL
Vital Signs
1257:
Blood Pressure 100/60 mm Hg
Temperature 98° F (36.7° C)
Heart rate 110/min
Respiratory rate 19 breaths per minute
Oxygen saturation 95% on room air
The client is demonstrating signs and symptoms of.
- A. urinary catheter obstruction
- B. hyponatremia
- C. shock
- D. urinary tract infection
Correct Answer: A
Rationale: Ketchup-like urine with clots and pelvic pressure post-TURP indicate catheter obstruction.
The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is at risk for hypokalemia? A client with
- A. hyperemesis gravidarum.
- B. end-stage renal failure.
- C. diabetic ketoacidosis.
- D. third-degree burns.
Correct Answer: A
Rationale: Hyperemesis gravidarum causes potassium loss through vomiting, increasing hypokalemia risk.
The nurse is placing a client with chronic kidney disease on a cardiac monitor. What is the reason for this action?
- A. Clients with chronic kidney disease are prone to hypertension
- B. Hyperkalemia may result in dysrhythmias
- C. Cardiac monitoring is necessary to evaluate the need for hemodialysis
- D. Clients with chronic kidney disease may experience false episodes of asystole
Correct Answer: B
Rationale: Hyperkalemia, common in CKD, can cause dysrhythmias, necessitating cardiac monitoring.