a nurse is caring for a client who is receiving magnesium sulfate for preeclampsia which finding indicates magnesium toxicity a nurse is caring for a client who is receiving magnesium sulfate for preeclampsia which finding indicates magnesium toxicity
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PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?

Correct answer: B

Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.

2. Which vaccine leaves a permanent scar at the site of injection?

Correct answer: A

Rationale: The BCG vaccine, which is used for tuberculosis, is known to leave a permanent scar at the site of injection. This distinctive scar formation is one of the characteristic features of receiving the BCG vaccine and is used as a marker of vaccination in some regions.

3. A client newly prescribed sertraline is being taught by a nurse. Which statement by the client indicates understanding?

Correct answer: B

Rationale: Choice B, 'I might have trouble sleeping when I start this medication,' indicates understanding because insomnia is a common side effect of sertraline, especially when initiating the medication. This statement shows the client comprehends a potential adverse effect and is prepared for it. Choices A, C, and D are incorrect. Taking sertraline with or without meals does not significantly affect its efficacy. There is no specific contraindication about drinking orange juice while on sertraline. Feeling better immediately after starting the medication is unlikely as sertraline usually takes some time to exert its therapeutic effects.

4. A healthcare professional is assessing a client who has a new prescription for furosemide. Which of the following findings should the healthcare professional report to the provider?

Correct answer: C

Rationale: The correct answer is C: Hypokalemia. Hypokalemia is a common electrolyte imbalance associated with furosemide use due to its diuretic effect, which can lead to potassium loss. It is crucial to report hypokalemia promptly to the provider as it can result in serious complications such as cardiac arrhythmias. Monitoring and managing potassium levels are essential in patients taking furosemide to prevent adverse effects related to electrolyte imbalances. Choices A, B, and D are incorrect findings to report in a client prescribed furosemide. Weight gain is not typically associated with furosemide use, a dry cough is more commonly linked to ACE inhibitors, and increased appetite is not a common adverse effect of furosemide.

5. Which of the following is an example of secondary prevention?

Correct answer: C

Rationale: Secondary prevention focuses on early detection and intervention to prevent the progression of diseases. Screening for hypertension falls under secondary prevention as it aims to identify the condition early, allowing for timely management and prevention of complications.

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