A nurse is assessing a client who has preeclampsia with severe features and is receiving intravenous magnesium sulfate. The nurse notes a respiratory rate of 8/min with absent deep tendon reflexes.
Which of the following actions is the nurse's priority?
Obtain a magnesium level.
Administer calcium gluconate.
Stop the magnesium sulfate infusion.
Take the client's blood pressure.
The Correct Answer is C
Choice A rationale
While obtaining a magnesium level is important for monitoring therapeutic range (typically 4-7 mEq/L), the client's current signs of respiratory depression (8/min) and absent deep tendon reflexes indicate severe magnesium toxicity, a life-threatening emergency. Immediate intervention is required to prevent respiratory arrest and cardiac complications.
Choice B rationale
Administering calcium gluconate is the antidote for magnesium sulfate toxicity because calcium ions competitively antagonize the effects of magnesium at the neuromuscular junction, reversing respiratory depression and cardiac effects. However, the priority action is to stop the causative agent first before administering the antidote.
Choice C rationale
Stopping the magnesium sulfate infusion is the most immediate and critical action to prevent further escalation of magnesium toxicity. The respiratory rate of 8/min is indicative of significant respiratory depression, a severe complication. Halting the infusion prevents additional magnesium from entering the bloodstream, allowing the body to excrete the excess.
Choice D rationale
Taking the client's blood pressure is part of a complete assessment; however, it is not the most immediate priority when the client is exhibiting severe signs of respiratory depression and absent deep tendon reflexes. These signs suggest impending respiratory arrest, which requires immediate intervention to preserve life.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fluid-filled vesicles on the chest are not characteristic of Koplik spots. Vesicular rashes are more commonly associated with conditions like varicella (chickenpox) or herpes zoster, where the viral replication leads to the formation of small, elevated, fluid-filled lesions on the skin surface.
Choice B rationale
Koplik spots are pathognomonic for measles, appearing as small, irregular, bright red spots with bluish-white centers on the buccal mucosa, typically opposite the molars. They represent necrotic epithelial cells in the buccal mucosa and are an early diagnostic sign, often appearing 2-3 days before the generalized rash.
Choice C rationale
Enlarged parotid glands are characteristic of mumps, a viral infection affecting the salivary glands, particularly the parotid glands. This condition leads to swelling and tenderness in the areas anterior to the ears and below the jawline, distinct from the oral lesions seen in measles.
Choice D rationale
A gray pseudomembrane covering the pharynx is a hallmark sign of diphtheria, a bacterial infection caused by *Corynebacterium diphtheriae*. This pseudomembrane is a tough, adherent lesion composed of fibrin, bacteria, and necrotic cells that can obstruct the airway, unrelated to measles.
Correct Answer is A
Explanation
Choice A rationale
The copper intrauterine device (IUD) is a highly effective, long-acting reversible contraceptive option that does not contain hormones. It works by releasing copper ions, which create an inflammatory reaction in the uterus, toxic to sperm and eggs, thus preventing fertilization and implantation. Its mechanism is entirely non-hormonal, meeting the client's request.
Choice B rationale
A cervical ring, often referring to a vaginal ring like the NuvaRing, releases hormones (estrogen and progestin) to prevent ovulation. This contradicts the client's request for a hormone-free method of contraception. Hormonal methods work by altering the menstrual cycle and preventing the release of an egg.
Choice C rationale
A cervical cap is a barrier method that requires the use of spermicide to be effective. While it is hormone-free, it is not considered "easy to use" as it requires precise placement over the cervix before each act of intercourse and removal afterward, often necessitating practice for proper insertion and fit.
Choice D rationale
A diaphragm is a barrier method that, similar to a cervical cap, requires the use of spermicide for efficacy. It must be inserted before intercourse and left in place for several hours afterward. This method, while hormone-free, is not considered "easy to use" due to the dexterity and understanding required for proper placement and removal.
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