Editing Reduction of Risk Potential – RN Practice Questions (section)

==Question 15==
A client with severe pre-eclampsia is receiving an intravenous magnesium sulfate infusion. The nurse finds the patellar deep tendon reflex absent, a respiratory rate of 10 breaths per minute, and urine output of 20 mL over the past hour. Which action should the nurse take first?
# Increase the infusion rate to control the blood pressure.
# Stop the magnesium sulfate infusion, notify the provider, and have calcium gluconate available.
# Administer a bolus of intravenous fluid and recheck reflexes in one hour.
# Document the findings as expected effects of therapy.

'''Answer:''' Option 2. Stop the magnesium sulfate infusion, notify the provider, and have calcium gluconate available.

''Rationale:'' Loss of deep tendon reflexes is the earliest reliable warning of magnesium toxicity, followed by respiratory depression, and it is compounded here by oliguria, since magnesium is renally excreted. The infusion is stopped immediately, the provider is notified, and calcium gluconate is the antidote. Option 1 would worsen toxicity. Option 3 delays intervention in the face of respiratory depression. Option 4 misclassifies dangerous toxicity as an expected effect; mild reduction in reflexes may be monitored closely, but absent reflexes with bradypnea and oliguria is not.

[[Category:Reduction of Risk Potential]]
[[Category:Registered Nurse (NCLEX-RN)]]
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