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?
Bradypnea
Tremors
Insomnia
Hypertension
The Correct Answer is A
A. Bradypnea: Magnesium sulfate toxicity depresses the central nervous system, leading to respiratory depression such as bradypnea. This is a critical sign requiring immediate intervention, as respiratory rates below 12 breaths per minute can be life-threatening.
B. Tremors: Tremors are typically associated with hypomagnesemia or withdrawal states, not magnesium toxicity. Magnesium toxicity causes muscle weakness and diminished reflexes rather than increased neuromuscular activity.
C. Insomnia: Insomnia is not a recognized symptom of magnesium toxicity. In contrast, elevated magnesium levels tend to cause sedation, lethargy, and decreased mental alertness.
D. Hypertension: Magnesium sulfate can actually lower blood pressure due to its vasodilatory effects. Hypertension would be inconsistent with toxicity and more commonly seen in preeclampsia before magnesium is administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “Place a warm, wet washcloth over your child’s forehead and the bridge of their nose.": Warm compresses can dilate blood vessels and potentially worsen the bleeding. A cold compress or direct pressure is more appropriate for stopping a nosebleed.
B. “Tell your child to blow their nose gently and then sit down and tilt their head backward.": Blowing the nose can dislodge clots and increase bleeding, and tilting the head backward risks aspiration of blood. The head should be tilted slightly forward.
C. “Use your thumb and forefinger to apply pressure to the sides of your child's nose.": Applying continuous pressure to the soft part of the nose for about 10 minutes helps compress blood vessels and promotes clot formation, which is the correct first-aid response for a nosebleed.
D. "Have your child lie down and turn their head to the side for 10 minutes.": Lying down can increase blood flow to the head and promote continued bleeding. Additionally, turning the head to the side risks aspiration of blood into the airway.
Correct Answer is D
Explanation
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.
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