A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion.

What nursing interventions are appropriate for this client? Select all that apply.

Monitor vital signs and urine output

Administer corticosteroids as prescribed

Check for signs of fluid overload or transfusion reaction

Encourage oral intake of fluids and electrolytes

Maintain bed rest and a quiet environment

Answer and Explanation

Correct Answer : A,C

The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction. Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure. The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.

Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity. Corticosteroids may worsen the liver function and increase the risk of infection.

Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome. Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.

Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome. The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible. Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.

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Correct Answer is A

Explanation

Respiratory rate of 10 breaths/min.

This is a sign ofmagnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia.Magnesium toxicity can causemuscle weakness,difficulty breathing,irregular heartbeats, andcardiac arrest.

Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.

Choice C is wrong because urine output of 40 mL/hour is adequate and does not indicate magnesium toxicity.

The minimum urine output for an adult is 30 mL/hour.

Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L and does not indicate magnesium toxicity.Magnesium levels above 2.6 mEq/L can indicate hypermagnesemia.

A. Calcium gluconate B. Naloxone C. Flumazenil D. Protamine sulfate

Correct Answer is A

Explanation

Calcium gluconate is the antidote for magnesium sulfate toxicity because it reverses the effects of magnesium on the neuromuscular and cardiovascular systems.

Magnesium sulfate can cause respiratory depression, hypotension, bradycardia, and cardiac arrest in high doses.

Choice B. Naloxone is wrong because it is the antidote for opioid overdose, not magnesium sulfate toxicity.

Naloxone blocks the opioid receptors and restores breathing and consciousness.

Choice C. Flumazenil is wrong because it is the antidote for benzodiazepine overdose, not magnesium sulfate toxicity.

Flumazenil binds to the benzodiazepine receptors and reverses the sedative and hypnotic effects.

Choice D. Protamine sulfate is wrong because it is the antidote for heparin overdose, not magnesium sulfate toxicity.

Protamine sulfate neutralizes the anticoagulant effect of heparin and prevents bleeding.

Normal ranges for magnesium are 1.5 to 2.5 mEq/L or 0.75 to 1.25 mmol/L.

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A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion. What nursing interventions are appropriate for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with severe pre-eclampsia who is receiving magnesium sulfate infusion. Which finding should alert the nurse to suspect magnesium toxicity?

Correct Answer is A

Explanation

A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate infusion. What is the antidote for magnesium sulfate toxicity?

Correct Answer is A

Explanation

A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion. What nursing interventions are appropriate for this client? Select all that apply.

A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin. The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds. The fetal heart rate is 160 beats/minute with late decelerations. What is the priority nursing action?

A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure. Which action should the nurse take first?

A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should alert the nurse to suspect magnesium toxicity?

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate. Which assessment finding would indicate that the client is experiencing magnesium toxicity?

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).

(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate. Which of the following values should the nurse report to the provider? (Select all that apply.)

A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?

A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion.

What nursing interventions are appropriate for this client? Select all that apply.