The nurse is assisting in the care of the client who is at 30 weeks of gestation.
Nurses' Notes
1200:
Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.
Encouraged client to cough and take deep breaths regularly.
Assisted with insertion of 18-gauge IV and initiation of IV fluid.
Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict input/output monitoring; total intake 180 mL/hour.
FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.
1400:
Magnesium sulfate infusion ongoing.
Client is lethargic. Heart rate regular 58bpm, blood pressure 148/99 mmHg, respirations shallow DTR 1+ bilaterally.
Urine output 20 mL in the last hour
1405:
Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.
1800:
Client is alert and responsive. Heart rate regular 78bpm, respirations even and unlabored. DTR 2+ bilaterally
Oxygen saturation (SaO) 95% on 2 L nasal cannula. Respiratory rate 18/min. Blood pressure 146/96 mm Hg.
Select the findings that indicate the client's condition has improved.
Urine output 40 mL in the last hour
Temperature 38.3°C(101 F)
Blood pressure 146/96 mm Hg
Deep tendon reflexes 2+ bilaterally
Heart rate 78/min
Correct Answer : D,E
Deep tendon reflexes (DTR): At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.
Heart rate: At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.
Other findings:
Urine output 40 mL in the last hour: Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.
Temperature 38.3°C (101°F): This indicates a fever, which is not a sign of improvement.
Blood pressure 146/96 mm Hg: Although this is better than a severely hypertensive reading, it is still elevated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. The nurse should tell the APs to stop the conversation, as they are violating the client's privacy and confidentiality by discussing their personal information in a public area. This is a breach of ethical and legal principles that can harm the client and expose the healthcare facility to liability. The other actions are not appropriate because they do not address the immediate issue or may escalate the situation unnecessarily. Submitting an incident report may be done after telling the APs to stop, informing the client may cause distress or anger, and documenting the event may not prevent further violations.
Correct Answer is B
Explanation
Explanation: The nurse should respect and support the client's decision to stop dialysis treatment, as it is an expression of autonomy and self-determination. Discussing alternative treatment methods, asking the facility chaplain to visit, and telling the client she should discuss this decision with her family are all actions that may imply that the nurse does not accept or respect the client's decision.
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