A nurse is caring for an adolescent client in a community health clinic.

 

Which of the following client statements indicate that the nurse's teaching about the immunization was effective? Select all that apply.

A. The client administers a PCA dose as soon as their pain returns: This is an appropriate action because PCA pumps are designed for the client to self-administer medication when pain begins to recur, maintaining adequate control and preventing severe discomfort.

B. The client is ambulating with the PCA pump: Ambulation with the PCA pump is acceptable as long as the pump is securely attached to an IV pole or portable stand and safety measures are followed. Mobility helps prevent postoperative complications such as deep vein thrombosis.

C. The client administers a PCA dose prior to dressing changes: Administering a dose before a painful procedure helps achieve optimal pain control, ensuring the client is comfortable during care activities.

D. The client requests their partner administer PCA doses while they sleep: The nurse should intervene because only the client should activate the PCA pump. Allowing another person to administer doses increases the risk of oversedation and respiratory depression, making this practice unsafe.

A. 1+ deep tendon reflexes: Decreased deep tendon reflexes indicate magnesium toxicity, as excessive magnesium depresses neuromuscular activity. This finding suggests the serum magnesium level may be too high and requires immediate reporting to prevent respiratory or cardiac complications.

B. Pupils equal, round, react to light, accommodation: Normal pupillary response does not indicate magnesium toxicity. This finding shows intact neurological function and does not require intervention.

C. Blood pressure 122/88 mm Hg: This blood pressure is within acceptable range for a client receiving magnesium sulfate for preeclampsia. It suggests that the medication is helping control hypertension without causing hypotension.

D. 24 hr urine output 960 mL: This urine output is adequate (greater than 30 mL/hr average) and indicates proper renal function. Since magnesium is excreted through the kidneys, normal urine output helps prevent accumulation and toxicity.