A nurse is collecting data from a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following findings should the nurse report to the provider?
2+ deep tendon reflex.
Facial flushing.
Respiratory rate 13/min.
Urine output 20 mL/hr.
The Correct Answer is D
A. 2+ deep tendon reflexes are within the expected range and are not typically concerning in a client receiving magnesium sulfate for preeclampsia.
B. Facial flushing can occur as a side effect of magnesium sulfate but is not typically a cause for immediate concern unless it is severe or accompanied by other symptoms.
C. A respiratory rate of 13/min is within the expected range and is not typically a concerning finding in a client receiving magnesium sulfate.
D. Urine output of 20 mL/hr is significantly decreased and may indicate reduced renal perfusion, which can be a serious complication of preeclampsia. Therefore, it should be reported to the provider for further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's right to refuse treatment, even if it is recommended by healthcare providers.
B. While it is important to communicate the client's wishes to the healthcare provider, the nurse should not threaten to report the client's decision without their consent. This could undermine trust between the nurse and the client.
C. While it is true that refusing treatment may have medical consequences, this statement may come across as judgmental or coercive. The nurse should provide information about the potential consequences of refusing treatment in a supportive and non-coercive manner.
D. Suggesting that the client consult with a clergyperson before making a treatment decision is not necessarily relevant to the client's medical decision-making process. It may also imply that the decision should be based on religious beliefs rather than personal values and preferences.
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Chest x-ray: Essential for visualizing the heart and lungs, which is critical in a patient with symptoms of heart failure and respiratory issues.
B. Basic metabolic profile (BMP): Important to assess electrolytes, renal function, and glucose levels, especially given the patient's history of diabetes and hypertension.
C. 12-lead ECG: Necessary for evaluating heart rhythm, rate, and to look for any ischemic changes, especially since the patient is experiencing tachycardia.
D. Doppler studies of lower extremities: While useful for assessing peripheral vascular disease, it is not as immediately relevant as the other tests for a direct diagnosis of heart failure.
E. Brain natriuretic peptide (BNP) level: A key diagnostic test for heart failure as elevated levels are indicative of cardiac stress.
F. Echocardiogram: Provides critical information on heart function and structure, which is essential for diagnosing and managing heart failure.
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