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 B
Explanation
A. While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B. Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C. While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D. While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.
Correct Answer is A
Explanation
A. Using an adhesive remover can help gently remove the colostomy appliance without causing skin irritation or damage. It can aid in maintaining skin integrity around the stoma.
B. Scrubbing the skin around the colostomy can cause skin trauma and increase the risk of infection. Gentle cleansing with warm water and mild soap is recommended.
C. There is typically no need to suction stool from a colostomy bag. Stool drainage occurs naturally into the bag, and suctioning is not a routine part of colostomy care.
D. Colostomy bags should be emptied when they are about one-third to one-half full to prevent
leakage and ensure comfort for the client. Waiting until the bag is three-fourths full may increase the risk of accidental leakage.
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