Nokea
The nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following findings would indicate magnesium toxicity?
- A. Respiratory rate of 18 breaths per minute.
- B. Deep tendon reflexes absent.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 140/90 mmHg.
Correct Answer: B
Rationale: absent deep tendon reflexes are a sign of magnesium toxicity, requiring immediate intervention
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For which of the following reasons would the nurse use the Braden Scale to assess a client?
- A. To determine if the client is suffering from delirium.
- B. To determine if the client is at risk for developing pressure sores.
- C. To determine if the client is at risk for falls.
- D. To determine if the client is at risk for substance abuse.
Correct Answer: B
Rationale: The Braden Scale assesses risk for pressure sores (B) by evaluating factors like mobility and skin moisture. It is not used for delirium (A), falls (C), or substance abuse (D).
The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:
- A. Add more water to the suction-control chamber
- B. Remove the drainage using a 60 mL syringe
- C. Milk the tubing to facilitate drainage
- D. Prepare a new unit for continuing collection
Correct Answer: D
Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
- A. Shave the area before applying the patch
- B. Remove the old patch and clean the skin with alcohol
- C. Cover the patch with plastic wrap and tape it in place
- D. Avoid cutting the patch because it will alter the dose
Correct Answer: B
Rationale: Removing the old patch and cleaning the skin with alcohol ensures proper adhesion and prevents irritation or overdose from residual medication.
A postoperative client whose oxygen saturation has been stable at 96% to 98% suddenly shows a drop to 80%. What initial response is most indicated?
- A. Notify physician.
- B. Administer oxygen.
- C. Assess client and reposition pulse oximeter.
- D. Collect an arterial specimen for ABGs.
Correct Answer: C
Rationale: Assessing and repositioning the pulse oximeter (C) checks for false readings first. Oxygen (B), notifying physician (A), or ABGs (D) follow if needed.