Nokea
The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?
- A. Urinary output of $60 \mathrm{ml}$ per hour
- B. Respirations of 30 per minute
- C. Absence of the knee-jerk reflex
- D. Blood pressure of $150 / 80$
Correct Answer: C
Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.
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The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
- A. Reporting joint stiffness in the morning
- B. Taking the medication 1 hour before or 2 hours after meals
- C. Using alcohol in moderation unless driving
- D. Continuing to take aspirin for short term relief
Correct Answer: B
Rationale: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.
Which symptom is considered an adverse reaction to Kantrex (kanamycin)?
- A. Diminished hearing
- B. Hypotension
- C. Hepatomegaly
- D. Petechiae
Correct Answer: A
Rationale: Kanamycin, an aminoglycoside, is ototoxic, and diminished hearing is a known adverse reaction requiring monitoring.
Following visitation, the nurse observes a client's wife sitting alone crying. When approached, the wife states, 'I'm so worried about him.' The best response by the nurse is:
- A. Are you worried about him being in the hospital?'
- B. Tell me what is worrying you.'
- C. Would you like to talk with the social worker assigned to your husband?'
- D. Would you like to talk with your husband's doctor?'
Correct Answer: B
Rationale: Tell me what is worrying you' encourages the wife to express her concerns, facilitating support. Other responses assume causes or defer to others prematurely.
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
- A. Administer PRN analgesic medication
- B. Administer PRN antihypertensive medication
- C. Lower the head of the bed
- D. Palpate the client’s bladder
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.
The doctor has ordered an IV of magnesium sulfate for a G1 P0 with preeclampsia. Which of the following symptoms is an expected side effect of magnesium sulfate?
- A. Oliguria
- B. Hypersomnolence
- C. Hyporeflexia
- D. Bradypnea
Correct Answer: C
Rationale: Hyporeflexia is an expected side effect of magnesium sulfate, used to monitor for toxicity in preeclampsia treatment.