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 D
Explanation
A. Insertion of a nasogastric tube: While informed consent is important for many procedures, the insertion of a nasogastric (NG) tube is generally considered a routine procedure that may not require formal informed consent unless specific complications or risks are involved.
B. Administration of an iron injection using Z-track technique: Informed consent is typically required for procedures with inherent risks or invasive elements, but routine administration of iron injections is not typically classified as needing informed consent, unless there are specific concerns.
C. Irrigation of a wound with antibiotic solution: Irrigation of a wound is typically a low-risk procedure, and although it is important to inform the client about the treatment, it generally does not require formal informed consent unless there are complications or risks involved.
D. Placement of a central venous catheter: Informed consent is required for the placement of a central venous catheter, as it is an invasive procedure with potential risks such as infection, bleeding, and damage to blood vessels. This procedure requires the nurse to obtain and document the client's consent before proceeding.
Correct Answer is A
Explanation
A. Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.
B. Using the room numbers of the clients is incorrect. Room numbers can change, and relying on them increases the risk of medication errors if a client is moved or misidentified.
C. Using the diagnoses of the clients is incorrect. A diagnosis is not a unique identifier, as multiple clients in a unit may have the same or similar conditions, leading to potential confusion.
D. Using the names of the clients' nearest relatives is incorrect. Family members’ names do not provide a direct, unique way to verify the client’s identity, making them unreliable for medication administration.
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