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The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
- A. Cool, clammy skin
- B. Altered sensorium
- C. Pulse oximeter reading of 95%
- D. Respiratory rate of less than 12 breaths per minute
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
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The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?
- A. Run lipids for no longer than 24 hours.
- B. Take down a running bag of TPN after 36 hours.
- C. Clean injection port with alcohol 5 seconds before and after use.
- D. Wear a sterile mask when changing the central venous catheter dressing.
Correct Answer: D
Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.
A nurse is standing beside the patient’s bed. Nurse:How are you doing? Patient:I don’t feel good. Which element will the nurse identify as feedback?
- A. Nurse
- B. Patient
- C. How are you doing?
- D. I don’t feel good.
Correct Answer: D
Rationale: In communication, feedback is the response or message provided by the receiver to the sender. In this scenario, the nurse asks the patient, "How are you doing?" The patient's response, "I don't feel good," is the feedback. It is the patient's reaction and message returning to the nurse. The nurse, in this context, is the sender initiating the conversation, while the patient is the receiver providing the feedback in response to the nurse's inquiry. Therefore, the statement "I don't feel good" constitutes the feedback in this communication exchange.
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
- A. Slight morning discharge from the eye
- B. Any appearance of redness of the eye
- C. A scratchy feeling in the eye
- D. A new floater in vision
Correct Answer: B
Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.
When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan?
- A. Increasing carbohydrates to 55% to 60% of total intake
- B. Providing vitamin and mineral supplements
- C. Decreasing protein intake to 0.75 g/kg/day
- D. Limiting water before and after exercise
Correct Answer: A
Rationale: When planning care for an adolescent who plays sports, it is important to provide adequate nutrition to meet their increased energy needs. Carbohydrates are the main source of energy, providing fuel for physical activity. Adolescents engaged in sports require a higher carbohydrate intake and should aim for 55% to 60% of their total daily kilocalories to support their activity levels. Carbohydrates are essential for providing energy during exercise, building and repairing muscles, and promoting overall performance. Increasing carbohydrate intake in the diet is a key modification to support the energy demands of an active adolescent involved in sports.
A nurse is discussing the advantages of a nursingclinical information system. Which advantage should the nurse describe?
- A. Varied clinical databases
- B. Reduced errors of omission
- C. Increased hospital costs
- D. More time to read charts
Correct Answer: B
Rationale: One of the key advantages associated with a nursing clinical information system is the reduction of errors of omission. By using an electronic system that prompts for required data entry and ensures completeness of documentation, nurses are less likely to miss important information, leading to improved patient care and safety. This advantage helps in promoting efficient communication among healthcare providers and contributes to better decision-making processes.