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 D
Explanation
A. "I will plan to spend time tanning between 10 a.m. and 2 p.m." UV radiation from the sun is strongest between 10 a.m. and 4 p.m., and sun exposure during this time significantly increases the risk of skin cancer. Outdoor activity should be minimized during peak hours.
B. "I will use an indoor tanning bed instead of going outside." Indoor tanning beds expose users to intense UV radiation, which also increases the risk of skin cancer. They are not a safer alternative to natural sunlight and should be avoided.
C. "I will use sunblock with an SPF of 10 when I am outdoors." SPF 10 provides minimal protection and is not adequate for skin cancer prevention. The recommended SPF is 30 or higher, applied generously and re-applied regularly.
D. "I will apply sunscreen before and after swimming." Sunscreen should be applied 15 to 30 minutes before sun exposure and re-applied every 2 hours, especially after swimming or sweating. This statement shows an understanding of proper sun protection practices.
Correct Answer is B
Explanation
A. Social worker. While a social worker can assist with emotional or financial concerns, they are not involved in managing oxygen delivery systems or therapy adherence related to medical devices.
B. Respiratory therapist. The respiratory therapist is the most appropriate team member to consult regarding oxygen delivery methods. They can assess the client’s needs, explain alternatives (e.g., nasal cannula instead of a mask), and help promote comfort and compliance with therapy.
C. Assistive personnel. Assistive personnel can support basic care tasks, but they are not trained to adjust or manage oxygen therapy or address client concerns about medical treatments.
D. Occupational therapist. Occupational therapists assist clients in regaining independence with daily activities, not in managing oxygen therapy. This issue is outside their scope of practice.
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