A charge nurse is educating a newly licensed nurse about fluid and electrolyte balance. Which of the following manifestations should the newly licensed nurse identify as a sign of magnesium sulfate toxicity?

A. Institutional policies and procedures: While institutional policies provide guidance on how tasks are performed within a facility, they cannot legally expand or limit a nurse’s scope of practice. Nurses must always ensure tasks are permitted by state law first.
B. Verbal direction from the nurse manager: Managers may offer direction, but their guidance should not override legal regulations. Relying solely on verbal instructions risks performing tasks outside the legal scope of practice, which can lead to liability issues.
C. State Nurse Practice Act: The Nurse Practice Act is a legal document specific to each state that defines the scope of practice for nurses. It outlines what tasks are legally permissible and serves as the most authoritative reference for professional responsibilities.
D. Written prescription from the provider: Although a provider can order treatments or procedures, nurses are still responsible for ensuring those actions fall within their legal scope. Following a prescription without verifying legality may result in practicing beyond licensure.

A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected after surgery and should be managed, but it is not immediately life-threatening or the highest priority.
B. The client refuses to look at the colostomy: Emotional adjustment is important, but this does not pose an immediate physical risk to the client and can be addressed over time with support and education.
C. The colostomy has had no output: It is common for a new colostomy to have delayed output within the first 24 hours postoperatively, so this finding is expected and not immediately concerning.
D. The stoma appears dark purple in color: A dark purple stoma indicates compromised blood flow or ischemia, which is a medical emergency requiring immediate intervention to prevent tissue necrosis and further complications.