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The nurse continues to care for the client who is at 30 weeks of

Exhibits

Complete the following sentence by using the lists of options.

Based on the client findings, the nurse should first

and then prepare to administer.
Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

A. Sit next to the client when speaking to them: Sitting in front of the client is more effective, as it allows the client to see the nurse’s facial expressions and lip movements, which can aid comprehension.
B. Lower the tone of voice at the end of each sentence: Lowering tone may make speech harder to hear. Many people with hearing loss have difficulty hearing low-pitched sounds, so lowering the tone can reduce clarity.
C. Emphasize vowel sounds when speaking: Vowel sounds are softer and less distinct than consonants. Emphasizing consonants and speaking clearly at a moderate pace is more effective than focusing on vowels.
D. Decrease background noise when talking with the client: Reducing background noise enhances the client's ability to hear and understand by minimizing auditory distractions, making this the most helpful communication strategy.

Correct Answer is A

Explanation

A. Muscle weakness: Hyperkalemia disrupts normal muscle cell function by affecting membrane excitability, leading to symptoms like muscle weakness or even paralysis in severe cases. It is one of the hallmark signs of elevated potassium levels.
B. Oliguria: While hyperkalemia may be associated with renal impairment, oliguria is not a direct manifestation of high potassium but rather a possible contributing factor. It is not specific to hyperkalemia itself.
C. Hypoactive bowel sounds: Increased potassium levels typically cause hyperactivity of the gastrointestinal tract, leading to hyperactive bowel sounds and cramping, not reduced or hypoactive activity.
D. Hypertension: Hyperkalemia more commonly results in hypotension due to its effects on cardiac conduction and vasculature. Hypertension is not a typical manifestation of elevated serum potassium.

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