A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?

Respiratory rate 10/min

2+ deep-tendon reflexes

3+ pedal edema

Urinary output 35 mL/hr

Answer and Explanation

The Correct Answer is A

A. Respiratory rate 10/min: Magnesium sulfate can cause central nervous system depression, and respiratory depression is a life-threatening adverse effect. A respiratory rate below 12/min indicates potential magnesium toxicity and requires immediate intervention, making it the priority assessment finding.

B. 2+ deep-tendon reflexes: A reflex grade of 2+ is normal and indicates that neuromuscular function is intact. While deep-tendon reflexes are monitored for magnesium toxicity, this finding does not represent an immediate threat.

C. 3+ pedal edema: Peripheral edema is a common finding in preeclampsia due to fluid shifts and vascular permeability. While it requires monitoring, it is not immediately life-threatening compared with respiratory depression.

D. Urinary output 35 mL/hr: Although reduced urine output can increase the risk of magnesium accumulation, 35 mL/hr is slightly below normal but not critically low. Monitoring is necessary, but the priority remains the depressed respiratory rate.

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Correct Answer is C

Explanation

A. "I can infuse the medication at a faster rate.": Infusing vancomycin faster than the recommended rate can cause adverse effects such as “red man syndrome,” hypotension, and cardiac arrhythmias. Rate adjustments must follow safe administration guidelines rather than client preference.

B. "I can adjust the time and schedule for when it's convenient for you.": Vancomycin dosing schedules are based on therapeutic drug levels and infection control, not convenience. Arbitrary adjustments could reduce efficacy or increase toxicity.

C. "I have up to 2 hours after the usual scheduled time to give you this medication.": Vancomycin can generally be administered within a 1–2 hour window of the scheduled time without compromising therapeutic effectiveness. This statement educates the client about safe timing while maintaining efficacy and adherence to clinical guidelines.

D. "I can start the medication 30 minutes earlier.": Administering vancomycin earlier than the recommended schedule may affect dosing intervals and drug serum levels. While minor adjustments may be permissible, starting early should follow provider orders and institutional protocols.

A. Headache B. Numbness and tingling of the extremities C. Increased salivation D. Sensation of skin warmth

Correct Answer is D

Explanation

A. Headache: Headache is not an expected finding during cardiac catheterization. If it occurs, it may indicate an unrelated issue such as anxiety, dehydration, or reaction to contrast dye, but it is not typical of the procedure itself.

B. Numbness and tingling of the extremities: Numbness and tingling are not expected during cardiac catheterization. These symptoms could suggest a complication such as nerve compression, impaired circulation, or allergic reaction, requiring immediate evaluation.

C. Increased salivation: Increased salivation is not associated with cardiac catheterization. This finding may be linked to oral stimulation or nausea, but it is not a normal response to the procedure.

D. Sensation of skin warmth: Clients often report a sensation of warmth or flushing during the injection of contrast dye used in cardiac catheterization. This response is expected and temporary, resulting from vasodilation and the chemical properties of the contrast medium.

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A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?

Nursing Test Bank

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Correct Answer is D

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