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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Correct Answer is D

Explanation

A. Water-soluble lubricant—not oil-based—is used to ease nasogastric tube insertion, as oil-based products can damage the tube or interfere with placement verification.

B. An enteric feeding pump is unnecessary for gastric decompression, which involves suctioning stomach contents rather than delivering nutrition.

C. Clean gloves, not sterile gloves, are sufficient for nasogastric tube insertion since it is a non-sterile procedure.

D. pH strips are essential to verify correct placement of the NG tube in the stomach, as aspirate pH helps ensure the tube is not in the lungs or intestines.

A. A client who has a history of pancreatitis and reports severe abdominal pain B. A client who has heart failure and reports severe dyspnea C. A client who is scheduled for abdominal surgery in 1 hr D. A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL

Correct Answer is B

Explanation

A. While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B. Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C. While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D. While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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