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The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
- A. Administer calcium gluconate
- B. Call the provider immediately
- C. Discontinue the magnesium sulfate
- D. Perform additional assessments
Correct Answer: C
Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.
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A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider?
- A. Diarrhea, vomiting, and mild tremor
- B. Dry mouth and mild thirst
- C. Hyperactivity and auditory hallucinations
- D. Lithium level of 1.3 mEq/L (1.3 mmol/L)
Correct Answer: A
Rationale: Diarrhea, vomiting, and tremor (A) suggest lithium toxicity, requiring immediate reporting. Dry mouth (B) is common, hallucinations (C) are unrelated, and a lithium level of 1.3 (D) is within therapeutic range.
The nurse is talking with a client who has type 1 diabetes mellitus and is receiving newly prescribed continuous subcutaneous insulin infusion therapy via an infusion pump. Which of the following statements by the client would indicate a correct understanding of the therapy?
- A. I will no longer need to test my blood glucose level throughout the day.
- B. I will no longer require an extra dose of insulin before my meals.
- C. My blood glucose levels should be more consistent throughout the day.
- D. The infusion set of my insulin pump should be changed daily.
Correct Answer: C
Rationale: Insulin pumps (C) provide steady insulin delivery, improving glucose stability. Glucose monitoring (A) and bolus doses (B) are still needed, and infusion sets are changed every 2-3 days, not daily (D).
Which of the following herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply.
- A. Black cohosh
- B. Garlic
- C. Ginger
- D. Ginkgo biloba
- E. Hawthorn
Correct Answer: B,C,D
Rationale: Garlic (B), ginger (C), and ginkgo biloba (D) have antiplatelet effects, increasing bleeding risk. Black cohosh (A) and hawthorn (E) do not significantly affect bleeding.
The mother is concerned that her 6-year-old child is eating dirt every day. The nurse is most concerned about which of the following?
- A. The child may not be getting enough to eat.
- B. The child may have lead poisoning.
- C. This is normal childhood behavior.
- D. The child may have iron deficiency anemia.
Correct Answer: B
Rationale: Pica, such as eating dirt, raises concern for lead poisoning, especially in children, as contaminated soil may contain lead, posing neurological risks.
The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.