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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Using an adhesive remover can help safely and effectively remove the adhesive residue from the skin without causing irritation or damage.
B. Scrubbing the skin around the colostomy can cause skin irritation and increase the risk of skin breakdown. Gentle cleaning with warm water and mild soap is recommended.
C. Most colostomy bags do not require suctioning of stool, as they are designed to collect fecal matter without the need for suctioning.
D. It is generally recommended to empty the colostomy bag when it is about one-third to one- half full to prevent leakage and maintain skin integrity.

A. The client's foot feels cooler than in the previous assessment. B. The client's pedal pulse in the right foot is not palpable. C. The client's capillary refill time is 5 seconds in the toes. D. The client reports a pain level of 8 on a scale from 0 to 10.

Correct Answer is B

Explanation

A. While a cooler foot than in the previous assessment may indicate decreased perfusion, the absence of a palpable pedal pulse is a more significant finding as it suggests compromised arterial blood flow to the foot.
B. The absence of a palpable pedal pulse indicates diminished arterial blood flow to the foot, which is a critical finding following a femoropopliteal bypass graft. It suggests potential complications such as graft occlusion or inadequate blood flow distal to the graft site.
C. Capillary refill time of 5 seconds in the toes may indicate delayed capillary refill, which could be a concern but is not as immediately critical as the absence of a palpable pedal pulse.

D. While pain is an important assessment finding, a pain level of 8 on a scale from 0 to 10 is subjective and does not provide specific information about the client's vascular status. Pain assessment should be considered along with other objective findings.

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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?

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