The nurse caring for a client receiving magnesium sulfate observes respirations of 10
breaths/minute, heart rate of 68 beats/minute, and blood pressure of 88/50 mm Hg. After
discontinuing the magnesium sulfate, which priority action would the nurse take?
A. Administer oxygen.
B. Initiate rescue breathing.
C. Initiate a bolus of intravenous (IV) fluid.
D. Administer calcium gluconate. correct answers D. Administer calcium gluconate. - the client
is experiencing magnesium sulfate toxicity, which can be reversed with calcium gluconate. If left
untreated, magnesium sulfate can result in respiratory or cardiac arrest.
A. B. C. - would not reverse the effects of magnesium sulfate
Which inference would the nurse draw when crackles are heard while auscultating the lung of a
client with severe preeclampsia?
A. Seizure activity is intermittent
B. Pulmonary edema may have developed
C. Diaphragmatic function is being impaired by the enlarged uterus
D. Bronchial constriction was precipitated by the stress of the pregnancy correct answers B.
Pulmonary edema is associated with severe preeclampsia; as vasospasms worse, capillary
endothelial damage results in capillary leakage into the alveoli.
A. Crackles are not an indication of an impending seizure; signs of an impending seizure include
hyperreflexia, developing or worsening clonus, severe headache, visual disturbances, and
epigastric pain.
C. Impaired diaphragmatic function is a discomfort associated with pregnancy that may result in
shortness of breath, not crackles.
D. Pregnancy does not precipitate bronchial constriction, although the hormones associated with
pregnancy can cause nasal congestion.
, Which response would the nurse make when a female client confides to the nurse that she enjoys
engaging in sex with multiple male partners simultaneously?
A. "I recommend that you seek counseling for this problem."
B. "Don't you think that having sex with multiple partners is immoral?"
C. "These men are abusing you, and you should go to the police and report them."
D. "What are you using for birth control and protection from sexually transmitted infections?"
correct answers D. The nurse would reply "What are you using for birth control and protection
from sexually transmitted infections?" Adults may have consensual sex as desired, but the nurse
would encourage the use of birth control and protection from STIs.
A. B. C. - The nurse is interjecting personal values by stating that the client should seek
counseling for this behavior or that the client's behavior is immoral. If the sex is consensual, it is
not abusive.
An adolescent woman who has become sexually active asks the nurse, "What's the most effective
way to prevent a pregnancy?" which method of preventing pregnancy should the nurse tell her is
the most effective?
A. Birth control pills
B. Spermicidal foam
C. Condoms
D. An intrauterine device (IUD) correct answers D. According to the U.S. Centers for Disease
Control and Prevention, having an intrauterine device inserted
provides a 99% effective means of preventing pregnancy. The intrauterine device, once placed,
requires no attention for it to be highly effective. Although refraining from sexual intercourse is
the most effective form of birth control (100% effective), this client has come to the nurse for
advice about how to prevent pregnancy while being sexually active.
A. The oral contraception pill is theoretically 99%
effective (91% effective with typical use).
B. Spermicidal foam is 82% effective with perfect use and 72% effective with typical use.