A client is scheduled receive a parenteral dose of magnesium sulfate. The nurse tests patellar reflexes and determines them to be absent. Which action by the nurse is the most appropriate?
1. Administer the drug as ordered, as this is a normal finding.
2. Hold the medication for 1 hour, then reassess.
3. Hold the medication and notify the health care provider.
4. Administer the drug after placing the client on a cardiac monitor.
Correct Answer: 3
Rationale 1: Absence of patellar reflexes is not a normal finding and is suggestive of magnesium toxicity.
Rationale 2: The health care provider should be notified about the absence of patellar reflexes, as the finding might indicate magnesium toxicity.
Rationale 3: Depression or absence of reflexes can indicate early magnesium intoxication.
Rationale 4: Absence of patellar reflexes is not a normal finding and is suggestive of magnesium toxicity.
Global Rationale: Depression or absence of reflexes can indicate early magnesium intoxication. Absence of patellar reflexes is not a normal finding and is suggestive of magnesium toxicity. The health care provider should be notified about the absence of patellar reflexes, as the finding might indicate magnesium toxicity. Absence of patellar reflexes is not a normal finding and is suggestive of magnesium toxicity.
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