A nurse is caring for a client at the clinic.

Complete the following sentence by using the lists of options.

The client is at risk for

_____

as evidenced by

_____

.

Rationale for correct choices

• Stop the magnesium sulfate infusion: The client exhibits signs of magnesium sulfate toxicity, including lethargy, shallow respirations, hyporeflexia (DTR 1+), and oliguria (urine output 20 mL/hr). Immediate cessation of the infusion is the priority to prevent progression to respiratory depression, coma, or cardiac arrest. Stopping the infusion reduces further magnesium accumulation and stabilizes the client.

• Calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity. It counteracts the neuromuscular and cardiac effects of magnesium, reversing hyporeflexia and respiratory depression. The nurse should prepare calcium gluconate IV for rapid administration while monitoring vital signs and respiratory status closely.

Rationale for incorrect choices

• Apply oxygen via nasal cannula: Although supplemental oxygen can support the client’s respiratory function, it does not reverse the toxic effects of magnesium. Oxygen therapy alone is insufficient in managing magnesium toxicity and is secondary to stopping the infusion.

• Place the client in Trendelenburg position: Trendelenburg positioning is not indicated and may worsen respiratory compromise. Maintaining a side-lying or semi-Fowler’s position is safer for airway management and monitoring during magnesium toxicity.

• Magnesium sulfate: Continuing magnesium sulfate would worsen toxicity, potentially leading to respiratory failure, cardiac arrest, and further CNS depression. Administration is contraindicated once toxicity signs appear.

• IV antibiotics: There is no indication of infection or sepsis in the client’s current assessment. Antibiotics do not address magnesium toxicity and are not warranted at this stage.

Rationale:

• Hypoxia: Hypoxia occurs in both epiglottitis and RSV due to airway obstruction or lower respiratory involvement. In epiglottitis, airway swelling can limit oxygen intake, whereas in RSV, lower airway inflammation and bronchiolitis cause oxygen desaturation. Streptococcal pharyngitis typically does not impair oxygenation.

• Fever: Fever is a nonspecific finding seen in epiglottitis, RSV, and streptococcal pharyngitis. Infection-induced inflammation and immune response in all three conditions cause elevated temperatures. The degree and onset of fever can vary among the conditions.

• Tachypnea: Tachypnea is a compensatory response to hypoxia and airway compromise. It is commonly observed in epiglottitis due to upper airway obstruction and in RSV due to bronchiolar inflammation. It is usually absent in isolated streptococcal pharyngitis.

• Drooling: Drooling is a hallmark sign of epiglottitis due to painful swallowing and airway obstruction. It is not typical in RSV or streptococcal pharyngitis. Presence of drooling indicates urgent airway assessment.

• Exudate on pharynx: Exudative pharyngitis is characteristic of streptococcal infections. It is rarely seen in epiglottitis and RSV. White or yellow exudates on the tonsils help differentiate bacterial pharyngitis from viral or upper airway conditions.

• Wheezing upon auscultation: Wheezing is associated with lower airway involvement, commonly seen in RSV bronchiolitis. It is not typically present in epiglottitis or streptococcal pharyngitis. Wheezing reflects bronchospasm or airway inflammation.