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+
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..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inspect the incision of a client who is postoperative following a leg amputation is incorrect. Inspecting an incision requires clinical assessment to identify signs of infection, dehiscence, or other complications, which should be performed by a licensed nurse.
B. Evaluate the need to suction the airway of a client who has a new tracheostomy is incorrect. Suctioning the airway of a client with a tracheostomy is a skilled task that requires assessment of the airway and airway management, which should be performed by a nurse.
C. Complete postmortem care for a client who has died is correct. Postmortem care, such as cleaning and preparing the body, is a task that can be delegated to an AP. The AP should not be involved in clinical assessments but can perform routine care under supervision.
D. Feed a client who has difficulty swallowing liquids following a stroke is incorrect. Feeding a client with swallowing difficulties requires careful monitoring and risk assessment for aspiration, which is outside the scope of tasks that can be delegated to an AP without proper training.
Correct Answer is D
Explanation
A. "My child still wets the bed at least two times per week." While this is a concern, bedwetting can be a normal developmental behavior for children at this age and does not necessarily indicate a problem unless it persists beyond the typical age range.
B. "I have a difficult time getting my child to eat green vegetables." This is a common concern for parents of young children and typically does not warrant immediate attention, although it may require guidance on healthy eating habits.
C. "My child continually asks me the same questions." Repetition of questions is a normal part of cognitive development in young children and does not indicate an issue by itself.
D. "I have noticed that my child is withdrawn since we switched day care providers." This is the priority concern. Withdrawal or behavioral changes, particularly after a significant event like a change in day care, can indicate stress, anxiety, or possible emotional issues, and the nurse should address this promptly to ensure the child's well-being.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
