A client with Preeclampsia is receiving Magnesium Sulfate IV continuous infusion. Which of the following findings should the nurse report to the provider?

Correct Answer: C

Rationale: In the context of a client with Preeclampsia receiving Magnesium Sulfate IV, the nurse should report a urinary output of 24 mL/hr to the provider. This finding is concerning because magnesium sulfate is excreted by the kidneys, and a decrease in urinary output may indicate magnesium toxicity, which can lead to serious complications such as respiratory depression and cardiac arrest. Option A (2+ deep tendon reflexes) is an expected finding in a client receiving magnesium sulfate, as it is used to prevent seizures by acting as a CNS depressant. Option B (2+ pedal edema) is a common symptom of preeclampsia and is not directly related to magnesium sulfate administration. Option D (respirations 12/min) is within the normal range and not a concerning finding in this context. Educationally, this question highlights the importance of monitoring clients receiving magnesium sulfate closely, particularly their urinary output, to prevent complications associated with magnesium toxicity. It also emphasizes the nurse's role in recognizing and reporting abnormal findings promptly to ensure patient safety.

Correct Answer: A

Rationale: In the case of a toddler admitted to the hospital after an Acetaminophen overdose, the nurse should anticipate administering Acetylcysteine. Acetylcysteine is the antidote for Acetaminophen overdose as it helps to replenish glutathione, a key antioxidant in the liver that gets depleted during Acetaminophen metabolism, thus preventing liver damage. Option B, Pegfilgrastim, is a medication used to stimulate the production of white blood cells in patients undergoing chemotherapy to prevent infections. This medication is not indicated for Acetaminophen overdose. Option C, Misoprostol, is a medication used to prevent stomach ulcers in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs). It is not the appropriate treatment for Acetaminophen overdose. Option D, Naltrexone, is a medication used to treat opioid and alcohol dependence by blocking the effects of opioids or alcohol in the brain. It is not indicated for Acetaminophen overdose. In an educational context, it is crucial for nurses and healthcare providers to be familiar with antidotes and appropriate treatments for medication overdoses to ensure prompt and effective patient care. Understanding the mechanisms of action and indications of medications is essential in providing safe and competent nursing care.

Correct Answer: C

Rationale: In this scenario, the correct response is C) The medication will relieve your mother's constipation. The rationale behind this is that Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist that is specifically used to treat opioid-induced constipation without affecting the central nervous system's analgesic effects of opioids like Morphine. By blocking the mu-opioid receptors in the gut, Methylnaltrexone helps to alleviate the constipation side effect caused by opioids without interfering with the pain relief provided by Morphine. Option A is incorrect because Methylnaltrexone does not increase respiration, as it is not centrally acting like traditional opioid antagonists such as Naloxone. Option B is incorrect because Methylnaltrexone does not prevent dependence on Morphine; its primary purpose is to address constipation. Option D is incorrect because while Methylnaltrexone does work in conjunction with Morphine, it does not directly increase pain relief but rather targets constipation. In an educational context, it is crucial for nurses to understand the rationale for using adjunct medications like Methylnaltrexone in managing side effects of opioid therapy. This knowledge enables healthcare providers to provide comprehensive care while minimizing adverse effects for patients with conditions like end-stage cancer.

Correct Answer: B

Rationale: In the context of administering Pamidronate for bone pain related to cancer, the correct precaution the nurse should take is option B) Assess the IV site for Thrombophlebitis frequently during administration. Pamidronate is a bisphosphonate medication that can cause irritation to the veins and increase the risk of thrombophlebitis when administered intravenously. Option A) is incorrect because Pamidronate is not typically associated with skin redness or irritation at the injection site. Option C) is incorrect as Pamidronate is usually given intravenously, not orally, so the instruction to lie down after oral administration is not relevant. Option D) is incorrect as anaphylaxis is not a common concern with Pamidronate administration. Educationally, understanding the specific side effects and precautions associated with medications like Pamidronate is crucial for nurses to ensure safe and effective administration to their patients. By knowing the potential complications and appropriate monitoring techniques, nurses can provide high-quality care and prevent adverse events during medication administration.

Correct Answer: C

Rationale: Regular insulin typically exhibits a peak effect approximately 1 to 5 hours after administration. It is important for clients to be aware of this timing to ensure optimal management of their blood glucose levels. Insulin glargine, NPH insulin, and Insulin lispro have different onset and peak times compared to Regular insulin, making them less likely to match the desired peak effect within the specified time frame.