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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tachycardia is not typically associated with opioid intoxication. Instead, bradycardia or normal heart rate may occur due to the depressant effects of opioids on the central nervous system.
B. Opioid intoxication often results in decreased mental alertness, leading to symptoms such as drowsiness, confusion, or even unconsciousness.
C. Hyperreflexia, or exaggerated reflexes, is not a common manifestation of opioid intoxication. Instead, hyporeflexia or depressed reflexes may occur due to the central nervous system depression caused by opioids.
D. Pinpoint pupils are a classic sign of opioid intoxication. Opioids bind to receptors in the brainstem, causing pupillary constriction. This effect is so characteristic that pinpoint pupils are often referred to as "opioid pupils."
Correct Answer is D
Explanation
A. Heart rate elevation could indicate pain, but it's an objective sign rather than subjective. Pain should be assessed based on the client's self-report.
B. Guarding the abdominal incision is an objective sign of pain and discomfort but does not reflect the client's perception of pain.
C. Facial grimacing is an objective sign of pain but may not always correlate with the client's perception of pain.
D. The client's report of pain is a subjective indication that they are experiencing discomfort and need PRN pain medication. It is essential to address the client's self-reported pain to provide adequate relief and promote comfort and recovery.
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