a nurse is caring for a client who is receiving magnesium sulfate for preeclampsia which of the following findings should the nurse report to the heal
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?

Correct answer: B

Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.

2. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his mother's room. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take is to respectfully deny the grandparent's request. In healthcare settings, strict security protocols are in place to ensure the safety of newborns. Only individuals with proper identification bracelets are allowed to transport newborns to prevent unauthorized individuals from taking them. Contacting the mother for verification would be time-consuming and may not be feasible immediately. Escorting the grandparent and newborn without proper identification would violate security protocols and compromise the newborn's safety. Notifying security should be done only if there is a threat or concern for safety, which is not the case in this scenario. Therefore, the best course of action is for the nurse to respectfully deny the grandparent's request to uphold the safety and security measures in place.

3. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?

Correct answer: A

Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.

4. A nurse is caring for a client with a prescription for duloxetine. Which of the following should the nurse monitor?

Correct answer: A

Rationale: The correct answer is A) Liver function. Duloxetine can affect liver function, making it crucial for the nurse to monitor liver function tests. Monitoring serum electrolytes (choice B), blood glucose (choice C), or potassium levels (choice D) is not directly associated with duloxetine use and would not be the priority in this case.

5. A client is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet?

Correct answer: C

Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, which can help prevent or address iron deficiency anemia. Yogurt (Choice A) and cheddar cheese (Choice D) are not significant sources of iron. While apples (Choice B) are a healthy fruit, they do not contain as much iron as raisins.

Similar Questions

A healthcare provider is caring for a patient and realizes they administered the wrong medication. What action should the healthcare provider take first?
A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which site is safest for the nurse to use?
A nurse is caring for a client who is 38 weeks pregnant and has a history of herpes simplex virus 2. Which question is most appropriate for the nurse to ask?
A client is prescribed tramadol for pain management. Which of the following should the nurse educate the client about?
A client with heart failure who presents with dyspnea, bibasilar crackles, and frothy sputum should receive which dietary recommendation?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses