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. Wearing a mask by family members is not typically necessary at home once the client is on effective treatment for tuberculosis and the infectious period has passed. The client should avoid public places and limit contact with vulnerable individuals, but family members do not need to wear masks at home after the initial treatment phase.
B. Long-term medication is required for tuberculosis, but not for the rest of the client’s life. Treatment usually lasts for 6-9 months, not a lifetime. Adherence to the medication regimen is crucial to prevent relapse or resistance.
C. Throwing away used tissues in a closed plastic bag is correct. This is a key infection control measure to prevent the spread of tuberculosis through respiratory droplets. Used tissues should be discarded in a closed, lined container, and the client should practice good hygiene.
D. No longer infectious after 30 days of treatment is incorrect. A client with tuberculosis may remain infectious until they have completed several weeks of treatment and show improvement. Typically, a negative sputum culture is used to confirm the client is no longer infectious.
Correct Answer is B
Explanation
A. "Provide informational updates to members of the media" is incorrect. This task typically falls under the responsibility of the hospital’s public relations or communications team. Nurses do not usually handle media updates in the context of mass casualty events.
B. "Assist in discharging stable clients to home" is correct. During a mass casualty event, it is important to make room for incoming patients. Discharging stable patients helps free up beds and resources for those who need immediate care.
C. "Delegate tasks to emergency health care specialists" is incorrect. While nurses may delegate some tasks, the nurse’s primary responsibility in this scenario would be managing care within the medical-surgical unit, not directing emergency health care specialists.
D. "Determine the acuity and number of casualties arriving at the facility" is incorrect. This task is generally managed by triage teams or emergency management staff who assess incoming patients at the point of injury or arrival at the facility.
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