A charge nurse is educating a newly licensed nurse about fluid and electrolyte balance. Which of the following manifestations should the newly licensed nurse identify as a sign of magnesium sulfate toxicity?

A. Allow the client to walk unassisted near the nursing station: Even in a monitored area, allowing an at-risk client to ambulate unassisted increases the chance of falling. Clients on fall precautions should always have supervision or assistive devices during ambulation.
B. Establish an elimination schedule for the client: Scheduled toileting reduces the risk of unassisted attempts to get out of bed, a common cause of falls in hospitalized clients. It supports safety by addressing one of the most frequent fall triggers.
C. Raise the four bed rails on the client’s bed: Using all four bed rails can be considered a form of restraint and may increase fall risk if the client tries to climb over them. Two or three side rails are safer and still provide support.
D. Silence the bed alarm when visitors are at the client’s bedside: Bed alarms are a key fall prevention tool. Silencing them reduces their effectiveness and can delay the response to unsupervised movement, even if visitors are present.

A. Remove the peripheral IV site: The IV site should be maintained with normal saline to keep access open for potential emergency medications or further treatment. Removing it too early may hinder urgent intervention.
B. Infuse 0.9% sodium chloride through the infusion set tubing: Normal saline should be infused after stopping the transfusion, but it must be done through new tubing to avoid continued exposure to the blood product.
C. Stop the transfusion of the blood: Itching and flushing are signs of a mild allergic transfusion reaction. The immediate priority is to stop the transfusion to prevent the reaction from progressing. This action helps prevent further antigen exposure.
D. Monitor the client's vital signs every 30 min: While vital sign monitoring is important, it is not the first or most urgent action. The priority is to stop the transfusion and address the reaction promptly.