A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?
Administer calcium gluconate
Discontinue the infusion.
Assess the fetal heart rate.
Obtain the client's magnesium level.
The Correct Answer is B
A. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity, but it should be given after stopping the infusion and assessing the client’s respiratory status. Immediate discontinuation takes priority.
B. Discontinue the infusion: Difficulty breathing indicates a potential magnesium sulfate toxicity or respiratory depression, which is a life-threatening emergency. The first action is to stop the infusion to prevent further accumulation.
C. Assess the fetal heart rate: Monitoring the fetus is important, but maternal safety takes priority over fetal assessment in a potential toxic reaction. Stabilizing the mother comes first.
D. Obtain the client's magnesium level: Lab assessment is useful for confirming toxicity, but it should not delay immediate intervention. Stopping the infusion takes precedence over obtaining levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "I allow myself 10 minutes to finish each client's dressing change.": Assigning a fixed time to every procedure may not be realistic, as dressing change complexity and patient needs can vary. Overly rigid timing can compromise quality of care and flexibility in prioritizing tasks.
B. "I try to be working on at least three tasks at once so I can finish on time.": Multitasking in nursing can lead to errors, incomplete documentation, and compromised patient safety. Prioritizing and completing tasks sequentially is more effective for accuracy and quality care.
C. "I do not document my interventions in the electronic medical records until the end of each shift.": Delayed documentation increases the risk of errors, omissions, and inaccurate reporting. Timely documentation is essential for continuity of care and legal accuracy.
D. "I perform stat and time-critical care as soon as I receive the provider's prescriptions.": Addressing urgent and time-sensitive tasks immediately ensures that critical needs are met without delay. This reflects appropriate prioritization and effective time management.
Correct Answer is A
Explanation
Rationale:
A. The child believes the person will return: Preschoolers view death as temporary and reversible due to their developmental stage and limited understanding of permanence. Magical thinking often leads them to expect the deceased person to come back.
B. The child focuses on his own mortality: This is more typical of older school-age children or adolescents, who have a more developed understanding of death’s permanence and may begin to consider their own vulnerability.
C. The child refuses to talk about the death: Avoidance can occur at any age, but it is not the primary expected response in preschoolers. At this stage, they may ask repetitive questions or make statements that suggest misunderstanding, rather than complete refusal to talk.
D. The child expresses curiosity about the death process: Curiosity about death’s physical aspects is more common in school-age children, who have greater cognitive ability to think concretely about biological processes.
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