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. This is the priority finding because it suggests respiratory depression, a serious side effect of magnesium sulfate therapy. Magnesium acts as a CNS depressant, and a respiratory rate below 12/min is a potential sign of magnesium toxicity, which can lead to respiratory arrest if not promptly addressed.
B. 2+ deep-tendon reflexes. This indicates normal neuromuscular function and is actually a reassuring finding in a client receiving magnesium sulfate. Reflexes are typically monitored to detect early signs of toxicity, and a 2+ rating means the dose is likely therapeutic.
C. 3+ pedal edema. While significant, pedal edema is a common feature of preeclampsia and not directly related to magnesium sulfate toxicity. It should be monitored but does not require immediate action compared to respiratory compromise.
D. Urinary output 35 mL/hr. This is slightly above the minimum acceptable output of 30 mL/hr, indicating the kidneys are excreting adequately. While magnesium is excreted renally and output must be monitored, this value does not indicate an acute risk.

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Correct Answer is C

Explanation

A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.

A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter

Correct Answer is D

Explanation

A. Request an interpreter of a different sex from the client. The interpreter's sex should be based on the client’s cultural preferences, not assumed by the nurse. This decision should be made to promote comfort and cultural sensitivity.
B. Request a family member or friend to interpret information for the client. This is not recommended, especially for medical discussions, as it may lead to misinterpretation, breaches of confidentiality, and biased communication.
C. Direct attention toward the interpreter when speaking to the client. The nurse should speak directly to the client, not the interpreter, to maintain a therapeutic relationship and respect for the client.
D. Review the facility policy about the use of an interpreter. This is the most appropriate initial action. Each facility typically has specific guidelines and procedures for accessing qualified medical interpreters, which the nurse should follow to ensure accurate and ethical communication.

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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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