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

Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia, a complication of pregnancy characterized by high blood pressure and organ dysfunction.Seizures are a sign of eclampsia, a severe form of preeclampsia that can be life-threatening.

Therefore, if the therapy is successful, the woman should not have any seizures.

Choice B.Absence of proteinuria is wrong because proteinuria, or excess protein in urine, is a possible sign of preeclampsia, not eclampsia.

Proteinuria may not disappear even after magnesium sulfate therapy.

Choice C.Absence of edema is wrong because edema, or swelling, is a common symptom of pregnancy and may not be related to preeclampsia or eclampsia.

Edema may not disappear even after magnesium sulfate therapy.

Choice D.Absence of headache is wrong because headache is a symptom of preeclampsia, not eclampsia.

Headache may not disappear even after magnesium sulfate therapy.

Normal ranges for blood pressure are below 140/90 mm Hg and for protein in urine are below 300 mg per 24 hours.

A. Respiratory rate 10/min B. Urine output 40 mL/hr C. Patellar reflex 2+ D. Serum magnesium level 4.5 mEq/L

Correct Answer is A

Explanation

Respiratory rate 10/min.This indicatesmuscle weaknessanddifficulty breathing, which are symptoms ofmagnesium toxicity.Magnesium sulfate is a medication that can cause magnesium overdose if given in excess or if the patient has impaired kidney function.

Choice B.Urine output 40 mL/hr is wrong because this is within the normal range for urine output, which is 30 to 50 mL/hr.Urine output may decrease in severe cases of magnesium toxicity due to urine retention.

Choice C. Patellar reflex 2+ is wrong because this is a normal finding for the knee-jerk reflex.A low or absent patellar reflex may indicate magnesium toxicity, as it reflectsmuscle weaknessandnerve dysfunction.

Choice D.Serum magnesium level 4.5 mEq/L is wrong because this is within the normal range for serum magnesium, which is 1.7 to 2.3 mEq/L.Serum magnesium levels above 2.6 mEq/L can indicate hypermagnesemia or magnesium overdose.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia. What clinical indicator would suggest that the therapy is successful?

Correct Answer is A

Explanation

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?

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 who has a diagnosis of HELLP syndrome. The nurse should monitor the client for which of the following complications? (Select all that apply.)

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

A nurse is caring for a client with eclampsia who is receiving magnesium sulfate and has a magnesium level of 10 mg/dL. Which of the following medications should the nurse have available as an antidote?

A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following assessments is the most important for the nurse to perform?

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 34 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia. Which of the following findings indicates a therapeutic response?

A nurse is providing discharge teaching to a client who had pre-eclampsia and delivered a healthy newborn. Which of the following statements by the client indicates an understanding of the teaching?

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.