A nurse is collecting data from a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following findings should the nurse report to the provider?
2+ deep tendon reflex.
Facial flushing.
Respiratory rate 13/min.
Urine output 20 mL/hr.
The Correct Answer is D
A. 2+ deep tendon reflexes are within the expected range and are not typically concerning in a client receiving magnesium sulfate for preeclampsia.
B. Facial flushing can occur as a side effect of magnesium sulfate but is not typically a cause for immediate concern unless it is severe or accompanied by other symptoms.
C. A respiratory rate of 13/min is within the expected range and is not typically a concerning finding in a client receiving magnesium sulfate.
D. Urine output of 20 mL/hr is significantly decreased and may indicate reduced renal perfusion, which can be a serious complication of preeclampsia. Therefore, it should be reported to the provider for further evaluation and management.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. Bupropion is not typically used as a first-line treatment for bulimia nervosa. Additionally, administering it before meals is not a standard practice for managing bulimia nervosa.
B. Incorrect. Allowing the client unrestricted access to food throughout the day may exacerbate binge-eating behaviors associated with bulimia nervosa. Structured meal plans are typically recommended instead.
C. Incorrect. While monitoring weight is important in the management of bulimia nervosa, weighing the client once weekly may not provide adequate monitoring, as fluctuations in weight can occur more frequently.
D. Correct. Observing the client for a period after meals helps to prevent purging behaviors, such as self-induced vomiting or misuse of laxatives, which are common in bulimia nervosa. This intervention allows for immediate intervention if purging behaviors are observed and can help ensure the client's safety.
Correct Answer is A
Explanation
A. Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B. Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C. Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D. Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.
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