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 A

Explanation

A. Heart rhythm: This is correct. Hypothermia, indicated by a body temperature of 32.5°C (90.5°F), can affect the cardiovascular system, potentially causing arrhythmias or even cardiac arrest. Monitoring heart rhythm is critical because of the risk of life-threatening cardiac complications associated with severe hypothermia.

B. Urinary output: While urinary output may decrease in hypothermic conditions due to vasoconstriction, it is not the priority. Cardiac function takes precedence, as severe hypothermia can lead to fatal arrhythmias.

C. Pain sensation: Although decreased pain sensation can occur in hypothermia, it is less urgent to monitor compared to the potential for life-threatening arrhythmias or cardiac arrest.

D. Muscle strength: While hypothermia can impair muscle strength, it is not the priority compared to monitoring for cardiac irregularities, which can be fatal if left unchecked.

A. Alternate daily caregivers. B. Remind the client of the day and time often. C. Offer the client several choices at mealtimes. D. Avoid discussing the client's fears.

Correct Answer is B

Explanation

A. Alternate daily caregivers is incorrect. Consistent caregiving is important for clients experiencing delirium to provide stability and reduce confusion. Frequent changes in caregivers can increase anxiety and disorientation.

B. Remind the client of the day and time often is correct. Frequent reminders of the day, time, and orientation help ground the client in reality and reduce confusion. This is an essential part of managing delirium by addressing disorientation and improving cognitive clarity.

C. Offer the client several choices at mealtimes is incorrect. Giving too many choices can lead to overwhelm and confusion in clients with delirium. It is better to offer simple, limited options to avoid stress or difficulty in decision-making.

D. Avoid discussing the client's fears is incorrect. Addressing a client's fears is important in the management of delirium. It is more beneficial to acknowledge and provide reassurance, which can help reduce anxiety and the psychological stress that might exacerbate delirium.

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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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