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

Answer and Explanation

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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Correct Answer is D

Explanation

A. The nurse cannot adjust IV antibiotic schedules solely for convenience, as consistent timing is necessary to maintain therapeutic drug levels.
B. Infusing vancomycin at a faster rate is unsafe and increases the risk of complications such as red man syndrome.
C. This is incorrect because the 2-hour administration window applies to non–time-critical medications. IV antibiotics like vancomycin are time-critical and must be given within 30 minutes of the scheduled time.
D. Time-critical medications, such as IV antibiotics, must be administered within 30 minutes before or after the scheduled time, making this the most accurate response.

A. Raise the head of the client's bed to a high-Fowler's position. B. Keep an abduction pillow between the client's legs. C. Elevate the client's affected leg on a pillow when in bed. D. Position the client's knees slightly higher than the hips when up in a chair.

Correct Answer is B

Explanation

A. Raise the head of the client's bed to a high-Fowler's position. A high-Fowler's position causes excessive hip flexion, which increases the risk of prosthetic dislocation after hip arthroplasty. Hip flexion should generally not exceed 90 degrees postoperatively.
B. Keep an abduction pillow between the client's legs. An abduction pillow maintains the leg in proper alignment and prevents internal rotation and adduction, which are common mechanisms of hip dislocation after surgery. It is a key intervention in protecting the surgical joint.
C. Elevate the client's affected leg on a pillow when in bed. Elevating the leg is appropriate for reducing swelling, but if not done correctly, it can cause improper hip positioning. It does not prevent dislocation unless combined with other alignment strategies.
D. Position the client's knees slightly higher than the hips when up in a chair. This position promotes hip flexion greater than 90 degrees, which increases the risk of dislocating the hip prosthesis. The hips should remain higher than the knees to prevent excessive flexion.

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A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?

Nursing Test Bank

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