More Questions on this Topic
More Questions on this Topic ( 35 Questions)
A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
Which of the following assessments is the most important for the nurse to perform?
Hourly intake and output is not the most important assessment for this client. However, the nurse should monitor the urinary output as a sign of renal function and fluid balance and report any output less than 30 ml per hour.
Deep tendon reflexes are not the most important assessment for this client. However, the nurse should check the reflexes as a sign of neuromuscular irritability and report any hyperreflexia or clonus.
Lung sounds are not the most important assessment for this client. However, the nurse should auscultate the lungs as a sign of pulmonary edema and report any crackles or wheezes.
This is because magnesium sulfate, which is given to prevent seizures in severe preeclampsia, can cause respiratory depression and coma if the dose is too high. Therefore, the nurse should monitor the client’s level of consciousness and respiratory rate closely and report any signs of toxicity to the provider.
Level of consciousness.
This is because magnesium sulfate, which is given to prevent seizures in severe preeclampsia, can cause respiratory depression and coma if the dose is too high. Therefore, the nurse should monitor the client’s level of consciousness and respiratory rate closely and report any signs of toxicity to the provider.
Choice A is wrong because hourly intake and output is not the most important assessment for this client. However, the nurse should monitor the urinary output as a sign of renal function and fluid balance and report any output less than 30 ml per hour.
Choice B is wrong because deep tendon reflexes are not the most important assessment for this client. However, the nurse should check the reflexes as a sign of neuromuscular irritability and report any hyperreflexia or clonus.
Choice C is wrong because lung sounds are not the most important assessment for this client. However, the nurse should auscultate the lungs as a sign of pulmonary edema and report any crackles or wheezes.