A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?
Respiratory rate 10/min
2+ deep-tendon reflexes
3+ pedal edema
Urinary output 35 mL/hr
The Correct Answer is A
A. Respiratory rate 10/min. This is the priority finding because it suggests respiratory depression, a serious side effect of magnesium sulfate therapy. Magnesium acts as a CNS depressant, and a respiratory rate below 12/min is a potential sign of magnesium toxicity, which can lead to respiratory arrest if not promptly addressed.
B. 2+ deep-tendon reflexes. This indicates normal neuromuscular function and is actually a reassuring finding in a client receiving magnesium sulfate. Reflexes are typically monitored to detect early signs of toxicity, and a 2+ rating means the dose is likely therapeutic.
C. 3+ pedal edema. While significant, pedal edema is a common feature of preeclampsia and not directly related to magnesium sulfate toxicity. It should be monitored but does not require immediate action compared to respiratory compromise.
D. Urinary output 35 mL/hr. This is slightly above the minimum acceptable output of 30 mL/hr, indicating the kidneys are excreting adequately. While magnesium is excreted renally and output must be monitored, this value does not indicate an acute risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Perform the Credé’s maneuver. This technique, involving manual pressure on the bladder, is used to promote urination in clients with bladder retention. It is not appropriate for a client with a catheter and continuous bladder irrigation in place.
B. Maintain the irrigation solution rate. Pink-tinged urine is an expected finding 4 hours after a TURP as minor bleeding can occur. There is no need to adjust the irrigation rate unless clots form or the urine becomes bright red or obstructed.
C. Warm the irrigation solution. Warming the solution is not a standard intervention and does not directly manage postoperative bleeding or pink urine. Room temperature solution is typically used unless otherwise specified by the provider.
D. Replace the indwelling urinary catheter. There is no indication the catheter is malfunctioning or obstructed. Pink urine alone does not warrant replacement, and unnecessary catheter changes can increase infection risk.
Correct Answer is C
Explanation
A. Educating clients about contraindications to specific immunizations. This is an example of primary prevention, which aims to prevent disease before it occurs by promoting safe practices and avoiding harmful exposures.
B. Providing clients with information about the benefits of exercise. This also falls under primary prevention, as it promotes a healthy lifestyle to prevent the onset of disease or complications.
C. Using an electronic messaging system to remind clients when to take medications. This is an example of tertiary prevention, which focuses on managing chronic conditions (like HIV) and preventing complications or progression of the disease through adherence support.
D. Helping clients understand health screenings covered by their insurance plans. This is considered secondary prevention, which involves early detection and prompt intervention to catch diseases in the early stages through screenings.
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