Renee Workman Scenario 5
Ten (10) minutes into the magnesium loading dose infusion the client states "I feel so hot I can't stand it!" Her spouse says, "Look how red her face is! What is happening? I'm so scared!" SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: Not all responses will be used.
1In a calm voice, remind the client and her wife that this is an expected side effect of the magnesium sulfate related to vasodilation.Important the nurse remains calm to then calm the client and wife. Flushing is an expected side effect.
2Use therapeutic touch and dim the lights in the room.Therapeutic touch demonstrates caring. Dimming the lights helps to decrease stimuli and seizure risk.
3Provide the client with a cool washcloth for her forehead; cover the client with sheet only and offer a fan.Applying the cool cloth and removing covers, yet maintaining privacy, help to decrease environmental temperature. These interventions can be completed quickly before assessing vital signs.
4Assess the client's vital signs and document FHR.Calming and cooling client prior to vital signs assessment so vital signs are less impacted by anxiety. Vital signs/FHR should be documented q 15 minutes during the magnesium infusion.
5Ask the wife to leave the client's room.Presence of 1 or 2 support persons is often calming to the client. Asking her wife to leave may increase the client's anxiety.
6Notify the healthcare provider of the adverse effects of the medication. (not used)Flushing is an expected side effect not an adverse reaction. The healthcare provider does not need to be notified at this time.