A nurse is planning care for a client who is at 31 weeks of gestation and has preeclampsia with severe features. The client has a new prescription for magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse plan to take?
Administer calcium gluconate for urine output less than 50 mL/hr.
Check deep tendon reflexes every 8 hr
Administer one dose of betamethasone now and repeat in 24 hr.
Limit IV intake to no more than 200 mL/hr.
The Correct Answer is C
A. Administer calcium gluconate for urine output less than 50 mL/hr: Calcium gluconate is given to treat magnesium sulfate toxicity, which is indicated by absent deep tendon reflexes, respiratory depression, or high serum magnesium levels. Low urine output requires monitoring but does not automatically warrant calcium gluconate administration.
B. Check deep tendon reflexes every 8 hr: Deep tendon reflexes should be assessed frequently during magnesium sulfate therapy, usually every 1–2 hours, to detect early signs of toxicity. Checking only every 8 hours is insufficient for safe monitoring.
C. Administer one dose of betamethasone now and repeat in 24 hr: Betamethasone is given to accelerate fetal lung maturity in preterm gestation, which is critical at 31 weeks. Administering the two-dose course as prescribed helps reduce neonatal respiratory complications, making this a priority intervention alongside magnesium sulfate therapy.
D. Limit IV intake to no more than 200 mL/hr: Monitoring and limiting IV fluids helps prevent fluid overload and pulmonary edema in preeclamptic clients, but ensuring fetal lung maturity with betamethasone takes priority at this gestational age in case of an early delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. "I can change my cat's litter box every day.": Clients with leukemia are immunocompromised and at increased risk for infections such as toxoplasmosis from cat feces. They should avoid changing litter boxes or use protective measures like gloves and masks, so this statement indicates a misunderstanding of infection prevention.
B. "I will avoid blowing my nose when I feel congested.": Avoiding forceful nose blowing helps prevent mucosal trauma and bleeding, which is important for clients with leukemia who may have thrombocytopenia or fragile mucous membranes. This statement demonstrates an understanding of precautions to reduce injury and infection risk.
C. "I can continue gardening in my yard.": Gardening exposes the client to soilborne pathogens and bacteria, increasing the risk of infection. Clients with leukemia should avoid activities that involve soil contact unless using strict protective measures, so this statement indicates a lack of understanding.
D. "I will clean my toothbrush with an alcohol-based mouthwash.": Cleaning a toothbrush with mouthwash is not sufficient to prevent microbial contamination. Clients with leukemia should use a soft-bristled toothbrush and replace it regularly to minimize infection risk. This statement reflects incomplete understanding of oral care precautions.
Correct Answer is A
Explanation
A. Offer high-calorie, high-protein snacks to the client: Providing nutrient-dense snacks helps address nutritional deficits caused by decreased appetite in depression. High-calorie, high-protein foods can improve energy levels, support overall health, and help prevent weight loss, which is a common concern in clients with depression.
B. Encourage the client to eat foods selected by the dietitian: While following a dietitian’s plan is beneficial, clients with depression and poor appetite may be resistant to structured meal plans. Offering flexible, appealing snacks is more practical and effective for ensuring adequate intake.
C. Weigh the client once each day: Daily weighing can be stressful or discouraging for clients with depression and may not directly improve nutritional intake. Weight monitoring is important but is secondary to actively supporting adequate nutrition through appealing foods.
D. Recommend the family provide the client privacy during meals: Privacy during meals may be helpful for some clients, but clients with depression often require encouragement, social support, and practical assistance to eat. Simply providing privacy may not address the underlying lack of appetite or insufficient nutrient intake.
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