A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.
Which of the following actions should the nurse include in the plan?

Give the client protamine if signs of magnesium sulfate toxicity occur.

Monitor the FHR via Doppler every 30 min.

Restrict the client's total fluid intake to 250 mL/hr.

Measure the client's urine output every hour.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Give the client protamine if signs of magnesium sulfate toxicity occur. Protamine is not the antidote for magnesium sulfate toxicity. Calcium gluconate or calcium chloride is used to counteract the effects of magnesium sulfate toxicity by antagonizing the action of magnesium on the neuromuscular junction and the heart.

Choice B rationale:

Monitor the FHR via Doppler every 30 min. While fetal heart rate (FHR) monitoring is important during magnesium sulfate infusion due to the risk of fetal distress, using Doppler every 30 minutes may not provide continuous and accurate monitoring. Continuous electronic fetal monitoring is the standard of care in this situation.

Choice C rationale:

Restrict the client's total fluid intake to 250 mL/hr. Magnesium sulfate is excreted by the kidneys, so maintaining adequate urine output is crucial to prevent magnesium toxicity. Restricting fluid intake to 250 mL/hr would likely reduce urine output, leading to an increased risk of magnesium sulfate accumulation in the body, which could be harmful.

Choice D rationale:

Measure the client's urine output every hour. Monitoring urine output is essential during magnesium sulfate infusion as it helps assess renal function and magnesium excretion. Adequate urine output (at least 30 mL/hr) is necessary to prevent magnesium toxicity. Therefore, measuring the client's urine output every hour is a critical nursing intervention to ensure the safety of the client.

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Correct Answer is B

Explanation

The correct answer is Choice B: "When using implanted contraceptive methods, condoms should also be used to protect against STDs."

Choice B rationale: While implanted contraceptive methods are highly effective in preventing unintended pregnancies, they do not provide protection against sexually transmitted diseases (STDs). Therefore, using condoms in conjunction with implanted contraceptives can enhance overall sexual health by reducing the risk of contracting or transmitting STDs. This statement highlights the nurse's understanding of the importance of comprehensive sexual health practices and the limitations of various contraceptive methods.

Choice A rationale: The use of petroleum-based lubricants with condoms can actually compromise their effectiveness. Petroleum-based lubricants can degrade latex condoms, increasing the likelihood of condom breakage or slippage, which in turn raises the risk of both pregnancy and STD transmission.

Choice C rationale: Condoms are indeed effective in preventing pregnancy, but their effectiveness can be enhanced by using them in conjunction with vaginal spermicides. Spermicides containing nonoxynol-9 can provide additional protection by inactivating or killing sperm, thus reducing the risk of pregnancy.

Choice D rationale: Ensuring a proper fit is crucial for a condom's effectiveness, but the statement only emphasizes the condom fitting snugly over the tip of the penis. For optimal protection, a condom should be unrolled to cover the entire erect penis, leaving a small empty space at the tip for semen collection. A condom that is not unrolled completely may be more likely to slip off or break during intercourse.

A. Improved short-term memory. B. Enhanced mood. C. Can perform ADLs independently. D. Increased food intake.

Correct Answer is A

Explanation

Choice A rationale:

Improved short-term memory. Donepezil is a medication used to treat Alzheimer's disease and other forms of dementia. It works by increasing the levels of certain chemicals in the brain that are involved in memory, thinking, and reasoning. Therefore, improved short-term memory is an indication that the medication is effective, as it suggests enhanced cognitive function in the client.

Choice B rationale:

Enhanced mood. While improved mood can be a positive outcome of treating dementia, it is not the primary goal of donepezil therapy. The main focus is on cognitive improvement, particularly in memory and thinking skills. Enhanced mood alone may not be a reliable indicator of the medication's effectiveness in this context.

Choice C rationale:

Can perform ADLs independently. The ability to perform activities of daily living (ADLs) independently is an important aspect of a patient's overall well-being. However, this improvement may not solely be attributed to the effects of donepezil. Other factors, such as rehabilitation or support services, can also contribute to the patient's ability to perform ADLs. While it is a positive outcome, it is not a specific indication of donepezil's effectiveness.

Choice D rationale:

Increased food intake. Increased food intake is not a direct effect of donepezil. Donepezil does not have a primary role in regulating appetite or food intake. Therefore, this finding is not a reliable indicator of the medication's effectiveness in treating dementia.

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A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil.Which of the following findings indicates that the medication is effective?

Correct Answer is A

Explanation

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A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.
Which of the following actions should the nurse include in the plan?