The nurse continues to care for the client who is at 30 weeks of
Complete the following sentence by using the lists of options.
Based on the client findings, the nurse should first
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for Correct Options:
- Apply oxygen via nasal cannula: The client is experiencing shallow respirations, SPO2 92%, lethargy, low urine output, and decreased DTRs, which are classic signs of magnesium sulfate toxicity. Administering oxygen helps improve oxygenation and mitigate hypoxia while preparing for further intervention.
- Calcium gluconate: This is the antidote for magnesium sulfate toxicity. Given the client’s clinical signs such as depressed DTRs, lethargy, and shallow breathing, immediate preparation and administration of calcium gluconate is essential to reverse potentially life-threatening effects.
Rationale for Incorrect Options:
- Reduce fluid intake: Although urine output is decreased, the primary concern is not fluid overload but rather signs of magnesium toxicity. Fluid restriction would not address the current emergent symptoms.
- Discontinue IV infusion: Magnesium sulfate infusion should be discontinued if toxicity is suspected, but it's not the first action compared to applying oxygen. The infusion should be stopped as soon as respiratory support is provided.
- Hydralazine: While this antihypertensive can treat severe hypertension in pregnancy, it is not the immediate priority in the setting of magnesium toxicity. Stabilizing respiratory and neurologic status takes precedence.
- Nifedipine: This antihypertensive has already been prescribed and possibly administered earlier. Re-administering it would not be the correct response to signs of magnesium toxicity, and could exacerbate hypotension or bradycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fibrinogen level: This test measures a clotting factor important for hemostasis, but it is not routinely used to monitor warfarin therapy. Fibrinogen levels are more relevant in evaluating bleeding disorders or liver function.
B. INR: The International Normalized Ratio is the standard test used to monitor warfarin effectiveness. It helps determine the appropriate dosing needed to maintain therapeutic anticoagulation and reduce the risk of bleeding or thromboembolism.
C. APTT: Activated partial thromboplastin time is used to monitor heparin therapy, not warfarin. It evaluates the intrinsic pathway of coagulation and is not a reliable indicator of warfarin activity.
D. Platelet count: While important in assessing bleeding risk, platelet count does not provide information on the anticoagulant effect of warfarin. It is not used to guide warfarin dosing decisions.
Correct Answer is A
Explanation
A. Fentanyl: This is a potent opioid analgesic used for severe pain, such as a pain level of 7 or higher. It is appropriate for managing acute, intense pain following injuries like fractures.
B. Hydrocodone: This opioid is typically used for moderate pain and may not provide sufficient relief for pain rated as 7 out of 10. It would be considered if the pain were less severe.
C. Aspirin: As a non-opioid analgesic, aspirin is suitable for mild to moderate pain and has anti-inflammatory effects. It would be inadequate for managing severe pain from a fractured leg.
D. Acetaminophen: Appropriate for mild to moderate pain, acetaminophen lacks the potency needed for severe pain and does not have anti-inflammatory properties to aid in tissue trauma like a fracture.
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