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+
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..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The grieving process should be complete within 1 year.: This is incorrect. Grief is a highly individual process and does not follow a strict timeline. It can last longer than one year for some individuals, depending on the relationship and circumstances.
B. Anticipatory grieving prolongs the grief process.: This is incorrect. Anticipatory grief, the grief experienced before the loss occurs, does not necessarily prolong the grieving process. In fact, it may help some individuals cope better after the loss because they have already begun to process their emotions.
C. Anger toward the health care staff is expected.: This is correct. It is normal for family members to experience anger during the grieving process, and sometimes they may direct it toward the healthcare staff, especially if they feel that the care is inadequate or if they are overwhelmed by emotions.
D. The stages of grief occur in sequential order.: This is incorrect. While Elisabeth Kübler-Ross identified five stages of grief (denial, anger, bargaining, depression, and acceptance., they do not necessarily occur in a linear or sequential order. Individuals may experience them in different ways and revisit stages at different times.
Correct Answer is ["C","D","E"]
Explanation
A. "The client in room 204 received some pain medicine earlier today." is incorrect. This statement is not specific enough to be relevant during change-of-shift report, as the timing of medication administration is important for the next nurse to know and track. A more precise update would be more helpful.
B. "The client in room 205 has had several visitors." is incorrect. While visitation may be useful to mention if it affects the patient's condition or treatment, it's not essential information for the nurse taking over the care of the client.
C. "The client in room 205 is scheduled for a dressing change at 1800." is correct. This provides necessary information about a planned procedure and ensures the next nurse is aware of it for timely management.
D. "The client in room 203 will undergo surgery at 0900 tomorrow." is correct. This provides critical information regarding the client's schedule and helps the next nurse prepare for the upcoming surgery.
E. "The client in room 204 has a new prescription for IV gentamicin." is correct. This is important information for the next nurse, as it indicates a change in the client's treatment plan and ensures appropriate medication administration.
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