A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Positive clonus

Urinary output 20 mL/hr

Respiratory rate 10/min

Deep tendon reflexes 2+

Answer and Explanation

The Correct Answer is D

A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.

B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.

C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.

D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..

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Correct Answer is C

Explanation

A. Medication: The medication, erythromycin, is appropriately prescribed. No clarification is needed regarding the medication.

B. Dosage: The prescribed dosage of 500 mg is a common dose for erythromycin, and there is no indication that it needs to be clarified.

C. Time: The prescription states that the medication is to be given four times per day, but the specific times (e.g., morning, noon, evening, bedtime. are not mentioned. The nurse should clarify the exact timing to ensure proper spacing of doses and avoid interactions.

D. Route: The route is typically oral for erythromycin, and there is no indication that clarification is needed.

A. Tachypnea B. Tachycardia C. Hypotension D. Hyperthermia

Correct Answer is C

Explanation

A. Tachypnea: Tachypnea (rapid breathing) is not a typical effect of magnesium sulfate. Magnesium sulfate is more likely to cause respiratory depression, especially at higher doses, rather than increasing the rate of breathing.

B. Tachycardia: Tachycardia (rapid heart rate). is not a common finding with magnesium sulfate administration. Magnesium sulfate typically causes a decrease in heart rate (bradycardia. and may also contribute to hypotension.

C. Hypotension: Hypotension is the correct finding. Magnesium sulfate has a vasodilatory effect, which can lead to a drop in blood pressure. This is a well-known side effect of magnesium sulfate, particularly when administered intravenously.

D. Hyperthermia: Hyperthermia (elevated body temperature). is not a typical finding associated with magnesium sulfate. Instead, magnesium sulfate can sometimes cause mild flushing, but it does not generally lead to an increase in body temperature.

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A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Nursing Test Bank

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