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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: b. Determine goals of the day.
Choice A: Schedule daily activities.
Rationale: Scheduling daily activities is crucial for time management but should follow establishing goals. The nurse must first determine the priorities and objectives for the day before organizing the tasks.
Choice B: Determine goals of the day.
Rationale: Identifying the goals of the day is the first step in effective time management for a nurse. This enables the nurse to prioritize patient care and other responsibilities, ensuring that essential tasks are accomplished and patient needs are met. Goals can include completing assessments, administering medications, and attending to patient concerns.
Choice C: Delegate tasks to the AP.
Rationale: Delegating tasks is vital in managing time and resources, but it should occur after the goals and priorities are determined. The nurse must first know which tasks need to be completed before assigning responsibilities to the LPN and AP.
Choice D: Develop an hourly time frame for tasks.
Rationale: Creating a timeline for tasks is essential for time management but should be done after setting goals and prioritizing tasks. This will enable the nurse to allocate an appropriate amount of time for each task and help ensure that all necessary tasks are completed within the shift.
In conclusion, by first determining the goals of the day, the nurse can effectively manage time and ensure that all essential tasks are completed. Prioritizing patient care and other responsibilities will enable the nurse to collaborate effectively with the LPN and AP in delegating tasks and scheduling activities.
Correct Answer is B
Explanation
The correct answer is **b. A room containing personal belongings.**
Choice A rationale:
A room without a window would not be a therapeutic environment for a cognitively impaired client. Lack of natural light and connection to the outside world can be disorienting and distressing for these patients.
Choice B rationale:
A room containing personal belongings is the most therapeutic environment for a cognitively impaired client. Familiar objects and surroundings can help provide a sense of comfort, security, and orientation. This can reduce agitation and confusion, which are common issues for cognitively impaired patients.
Choice C rationale:
A room adjacent to the nursing station may not be the most therapeutic environment. While proximity to staff can be beneficial, the increased noise and activity level near the nursing station could be overstimulating and disruptive for a cognitively impaired client.
Choice D rationale:
A room with dim lighting is not ideal for a cognitively impaired client. Adequate lighting is important to help these patients maintain orientation and avoid falls or other safety issues. Dim lighting can contribute to confusion and disorientation.
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