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NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?
A. Initiate continuous cardiac monitoring.
The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.
B. Administer 40 mEq/L potassium chloride PO with orange juice.
The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.
C. Provide a diet rich in legumes, nuts, and green vegetables.
The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.
D. Monitor the client for tetany.
The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
- A. Correct. The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.
- B. Incorrect. The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.
- C. Incorrect. The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.
- D. Incorrect. The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs
Similar Questions
A nurse is caring for a client who is pregnant.
Nurses' Notes 1000:
The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.
1015:
IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.
1100:
Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.
The nurse is providing discharge teaching to the client.
For each discharge instruction, specify if each action is recommended or contraindicated for the client.
A. Alternate eating solid foods and liquids
Alternate eating solid foods and liquids is recommended. This can help prevent dehydration and malnutrition, as well as reduce the risk of vomiting by avoiding overfilling the stomach.
B. Eat every 2 to 3 hr
Eat every 2 to 3 hr is recommended. This can help maintain blood glucose levels and prevent hunger-induced nausea.
C. Drink warm ginger ale when nauseated
Drink warm ginger ale when nauseated is recommended. Ginger has antiemetic properties and can help soothe the stomach and reduce nausea.
D. Increase intake of high-fat foods
Increase intake of high-fat foods is contraindicated. High-fat foods can delay gastric emptying and worsen nausea and vomiting. The client should eat low-fat, bland, and easy-todigest foods instead.
E. Recommended actions
Recommended actions is correct. The nurse should indicate which actions are recommended for the client.
Full Explanation
Correct answer: A, B, C, E
Rationale:
- A: Alternate eating solid foods and liquids is recommended. This can help prevent dehydration and malnutrition, as well as reduce the risk of vomiting by avoiding overfilling the stomach.
- B: Eat every 2 to 3 hr is recommended. This can help maintain blood glucose levels and prevent hunger-induced nausea.
- C: Drink warm ginger ale when nauseated is recommended. Ginger has antiemetic properties and can help soothe the stomach and reduce nausea.
- E: Recommended actions is correct. The nurse should indicate which actions are recommended for the client.
- D: Increase intake of high-fat foods is contraindicated. High-fat foods can delay gastric emptying and worsen nausea and vomiting. The client should eat low-fat, bland, and easy-todigest foods instead.
A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?
A. Respiratory alkalosis
The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).
B. Metabolic alkalosis
The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).
C. Respiratory acidosis
The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
D. Metabolic acidosis
The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).
Full Explanation
- A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).
- B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).
- C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
- D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).
A nurse is caring for a client who has bulimia nervosa.
Select words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing and