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 A
Explanation
Rationale:
A. Adequate hydration: Maintaining proper fluid intake helps reduce blood viscosity and prevents sickling of red blood cells. Dehydration is a common trigger for sickle cell crises, so emphasizing hydration is crucial for prevention.
B. Increased iron intake: Most clients with sickle cell anemia do not require additional iron unless they have documented iron deficiency. Excess iron can accumulate and cause complications, especially in those receiving frequent transfusions.
C. Calorie restriction: Restricting calories is not recommended, as children with sickle cell anemia often have increased metabolic needs due to chronic hemolysis and may require adequate nutrition for growth and energy.
D. A low-protein diet: Protein is important for growth, tissue repair, and overall health. A low-protein diet is not indicated and could worsen nutritional status in children with sickle cell disease.
Correct Answer is A
Explanation
A. "Since I retired, I have entered many gardening competitions.": Compensation involves emphasizing a strength or engaging in alternative activities to make up for perceived deficiencies or losses. Participating in competitions reflects the client redirecting energy to excel in another area, consistent with this defense mechanism.
B. "I'm so glad I've retired because the work was making me sick and depressed.": This statement reflects relief and rationalization rather than compensation, as the client is explaining the retirement in terms of health and well-being.
C. "There were lay-offs at my company, so I journaled about what I accomplished during my career.": Journaling is a coping strategy that promotes reflection and self-esteem, but it is more aligned with intellectualization or sublimation, not compensation.
D. "I had to retire because my boss didn't like me.": This statement demonstrates projection, attributing responsibility for a situation to someone else, rather than compensating for perceived loss or inadequacy.
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