which of the following might the nurse assess in a patient diagnosed with hypermagnesemia

ATI RN

Fluid and Electrolytes ATI

1. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?

A. Diminished deep tendon reflexes
B. Tachycardia
C. Cool clammy skin
D. Increased serum magnesium

Correct answer: A

Rationale: The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.

2. Place a washcloth between the skin and tourniquet

A. Provide a bed bath instead of letting the client take a shower
B. Use sterile technique when changing the dressing.
C. Disconnect the intravenous fluid tubing prior to the clients bath.
D. Use a plastic bag to cover the extremity with the device

Correct answer: D

Rationale:

3. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

A. I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup
B. Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
C. It is normal to be a little confused following surgery, and it is safe not to urinate at night.
D. If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Correct answer: B

Rationale:

4. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

A. Ask family members to speak quietly to keep the client calm.
B. Assess urine color, amount, and specific gravity each day.
C. Encourage the client to drink at least 1 liter of fluids each shift.
D. Dangle the client on the bedside before ambulating.

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.