Difficulty: Medium
Average Score: 68%
Simulated
A nurse is caring for a client who is receiving continuous IV infusion of magnesium sulfate. Which of the following findings should the nurse report to the provider?
Correct answer
B
Rationale
The correct answer is B: Patellar reflex absent. Absence of patellar reflex may indicate magnesium toxicity, which can lead to respiratory depression and cardiac arrest. A respiratory rate of 14/min, urine output of 30 mL/hr, and blood pressure of 130/80 mm Hg are within normal ranges and not immediate concerns with magnesium sulfate infusion. Reporting the absent patellar reflex is crucial to prevent serious complications.