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
D
The information is an indication of magnesium sulfate toxicity that should be reported to the health care provider. Charting the findings is an important intervention, but it is not the priority action. Checking for clonus is not an appropriate action at this time. Decreasing the magnesium sulfate is not a nursing intervention without health care provider prescription.
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