Diagnostic Criteria and Investigations
Diagnostic Criteria and Investigations ( 16 Questions)
A nurse is preparing to administer magnesium sulfate IV to a client who has severe pre-eclampsia.
Which of the following actions should the nurse take? (Select all that apply.)
The nurse should monitor the client’s deep tendon reflexes hourly because magnesium sulfate can cause neuromuscular blockade and decreased reflexes.
The nurse should keep calcium gluconate readily available because it is the antidote for magnesium toxicity.
The nurse should maintain a urine output of at least 40 mL/hr because magnesium is excreted by the kidneys and low urine output can indicate renal impairment or fluid overload.
The medication should not be infused via a peripheral IV line, but rather through a central line or a large-bore IV catheter to prevent tissue damage.
The nurse should check the client’s blood pressure every 15 minutes because magnesium sulfate can cause hypotension and preeclampsia can cause hypertension.
The correct answer is choice A, B, C and E. The nurse should monitor the client’s deep tendon reflexes hourly because magnesium sulfate can cause neuromuscular blockade and decreased reflexes. The nurse should keep calcium gluconate readily available because it is the antidote for magnesium toxicity. The nurse should maintain a urine output of at least 40 mL/hr because magnesium is excreted by the kidneys and low urine output can indicate renal impairment or fluid overload. The nurse should check the client’s blood pressure every 15 minutes because magnesium sulfate can cause hypotension and preeclampsia can cause hypertension.
Choice D is wrong because the medication should not be infused via a peripheral IV line, but rather through a central line or a large-bore IV catheter to prevent tissue damage.
