A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Positive clonus

Urinary output 20 mL/hr

Respiratory rate 10/min

Deep tendon reflexes 2+

Answer and Explanation

The Correct Answer is D

A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.

B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.

C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.

D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..

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Correct Answer is B

Explanation

A. Family history of cardiovascular disease: This is a non-modifiable risk factor. Family history can increase the likelihood of cardiovascular disease, but it cannot be changed.

B. Cholesterol 240 mg/dL: This is a modifiable risk factor. High cholesterol levels, particularly above 200 mg/dL, increase the risk of cardiovascular disease, and they can be managed through lifestyle changes, diet, and medication.

C. Sex: This is a non-modifiable risk factor. Men are generally at higher risk for cardiovascular disease at a younger age, while the risk increases for women after menopause.

D. Age 65: This is a non-modifiable risk factor. As people age, their risk for cardiovascular disease increases.

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." B. "An incident report has been completed and sent to risk management." C. "The client fell because the assistive personnel did not place nonskid slippers on the client." D. "The client does not appear to have any injuries resulting from the fall."

Correct Answer is A

Explanation

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." This is the correct choice. The nurse should document the client's own account of the event in the medical record. It is important to accurately record the client's statement, as documentation should reflect the facts and avoid interpretation or assumptions.

B. "An incident report has been completed and sent to risk management." This statement should not be included in the client's medical record. Incident reports are separate from clinical documentation and are not part of the patient's permanent medical record.

C. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement makes an assumption about the cause of the fall and includes blame, which is inappropriate for medical documentation. Documentation should focus on objective observations and the client's statement, not assigning fault.

D. "The client does not appear to have any injuries resulting from the fall." While the nurse may assess the client for injuries, this statement should not be included unless it is confirmed and part of a thorough, objective assessment. It’s important to document specific findings (e.g., "No visible injuries noted").

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A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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