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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.
Correct Answer is B
Explanation
A. Have the client store smaller tanks under his bed. Oxygen tanks should never be stored in enclosed or confined spaces such as under a bed due to the risk of fire and poor ventilation, which can increase the danger of oxygen accumulation.
B. Place the oxygen tank away from curtains or drapes. This is essential to reduce the risk of fire. Oxygen supports combustion, so keeping the tank away from flammable materials like curtains helps ensure a safe home environment.
C. Store the oxygen tank wrench in a locked cabinet. The wrench should be kept accessible, not locked away, to allow quick adjustments or shut-off in case of emergency. Immediate access is a priority in safe oxygen use.
D. Ensure that the client checks the gauge weekly. The oxygen tank gauge should be monitored more frequently than once a week to avoid running out of oxygen unexpectedly, especially in clients with chronic respiratory conditions like COPD.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.