A nurse is caring for a client with gestational hypertension who has been prescribed magnesium sulfate to prevent seizures related to preeclampsia.
Which of the following assessments should the nurse prioritize?
Respiratory rate and depth
Urine output and color
Blood pressure and heart rate
Level of consciousness and reflexes
The Correct Answer is D
The correct answer is choice D) Level of consciousness and reflexes. This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes. These are signs that the dose of magnesium sulfate should be reduced or stopped.
The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.
Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.
Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures. However, urine output should be monitored to ensure adequate hydration and renal function.
Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy. Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Hemoglobin 6 g/dL, platelets 25,000/mm3, AST 120 U/L, ALT 100 U/L.
This is because HELLP syndrome is a pregnancy complication that causes hemolysis (breaking down of red blood cells), elevated liver enzymes (indicating liver injury), and low platelet count (impairing blood clotting).
Choice A is wrong because hemoglobin 12 g/dL, platelets 150,000/mm3, AST 20 U/L, ALT 18 U/L are all within normal ranges and do not indicate HELLP syndrome.
Choice B is wrong because hemoglobin 10 g/dL, platelets 100,000/mm3, AST 40 U/L, ALT 35 U/L are mildly abnormal and may suggest mild preeclampsia but not HELLP syndrome.
Choice C is wrong because hemoglobin 8 g/dL, platelets 50,000/mm3, AST 80 U/L, ALT 70 U/L are moderately abnormal and may suggest moderate preeclampsia or incomplete HELLP syndrome but not full HELLP syndrome.
Normal ranges for these laboratory tests are:
• Hemoglobin: 11.5 to 16.5 g/dL for women.
• Platelets: 150,000 to 450,000/mm3 for adults.
• AST: 10 to 40 U/L for adults.
• ALT: 7 to 56 U/L for adults.
Correct Answer is ["A","B"]
Explanation
The correct answer is choice A and B. Hydralazine is a drug that lowers blood pressure by relaxing the blood vessels.It can cause some side effects such astachycardia(fast heart rate) andheadache.
These are common and may go away during treatment.
However, if they are severe or persistent, the nurse should monitor the client and report to the doctor.
Choice C is wrong because nausea is not a common side effect of hydralazine.
It may be caused by other factors such as pregnancy or infection.
Choice D is wrong because hyperkalemia (high potassium level in the blood) is not a side effect of hydralazine.
It may be caused by other drugs such as angiotensin-converting enzyme inhibitors or potassium-sparing diuretics.
Choice E is wrong because oliguria (low urine output) is not a side effect of hydralazine.
It may be a sign of kidney damage or dehydration.
The nurse should monitor the client’s fluid intake and output and report any changes to the doctor.
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.