While assessing a client with PIH on magnesium sulfate, the nurse finds that her output for the last hour was 30 mL, her respiratory rate is 20 per minute, her blood pressure is 150/94, and her deep tendon reflexes are absent.
The nurse's next response would be to a. chart her findings c. decrease the magnesium sulfate
b. check for clonus d. notify the physician
Question 2
A baby in the nursery is 18 hours old. Which piece of information would be most essential to pass on to the next shift?
a. Infant has milky discharge from the nipples.
b. Infant has not voided.
c. Infant has polydactyly on each hand.
d. Testes are descended on only one side.
Rinne Test, Assessing Air Conduction
Client on IV patient-controlled analgesia (PCA).
Assessing skin turgor.
The nurse applies a pulse oximeter sensor on the client’s finger.
Testing patellar reflex, client in a sitting position