The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)

Correct Answer: B

Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.

Correct Answer: D

Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.

Correct Answer: A

Rationale: Challenging communication situations in nursing care typically involve patients who exhibit behaviors that make communication difficult or complex. In the given options, a child who is developmentally delayed (Option A) and an older-adult patient who is demanding (Option B) are examples of patients who may have challenging communication issues.

Correct Answer: B

Rationale: The preceptor would need to follow up with the new nurse for charting consecutively on every other line. This behavior is incorrect as it can lead to confusion and potential errors in documentation. Correct charting practice involves documenting consecutively, line by line without skipping lines in between. The preceptor should provide guidance and correction to ensure accurate and organized documentation for patient care.

Correct Answer: A

Rationale: The best time for a nurse to start discharge planning for a patient admitted with pneumonia and a congested cough is upon admission. Starting discharge planning early allows the healthcare team to identify the patient's needs, plan for the appropriate level of care, and ensure a smooth transition out of the hospital. Waiting until right before discharge or after the congestion is treated may lead to rushed or incomplete planning, potentially compromising the patient's recovery and post-discharge care. Additionally, discharge planning is not dependent on the primary care provider writing an order, as nurses can initiate teaching and planning proactively to support the patient's optimal recovery and transition. By beginning discharge planning upon admission, the healthcare team can address any potential barriers to discharge and ensure the patient's needs are met for a successful recovery process.