NCLEX Reduction of Risk Potential

Correct! Metformin must be held before procedures using iodinated intravenous contrast because contrast agents can cause acute kidney injury. If renal function is impaired, metformin accumulates (since it is renally cleared) and can cause lactic acidosis — a rare but potentially fatal complication. The standard protocol is to hold metformin on the day of the procedure and for 48 hours after, then assess renal function before restarting.

Clinical pearl: Clinical Pearl: Metformin and contrast protocol: hold metformin on the day of the contrast procedure. After the procedure, recheck renal function (creatinine, eGFR) at 48 hours. If renal function is stable and adequate, metformin can be restarted. This applies to all forms of iodinated contrast — intravenous, intra-arterial, and intrathecal. Alert the radiology team and provider about metformin use during any pre-procedure assessment.

Correct! Bupivacaine administered as a spinal anesthetic for lower extremity surgery typically produces motor and sensory block lasting three to five hours — sometimes longer depending on the dose and baricity. Four hours after the procedure, residual block with inability to move the legs and absent sensation below the waist is within the expected range of spinal anesthesia duration. The nurse should document baseline neurological findings and monitor for progressive return of sensation (typically returns before motor function) and motor function.

Clinical pearl: Clinical Pearl: Spinal anesthesia recovery: sensation returns before motor function in reverse order from the level of anesthesia. Monitor for return of perianal sensation (perineal sensation returns last), then toe flexion, then knee flexion, then hip flexion as the block recedes. Document the level of block and time of each function return. Do not allow ambulation until the client has full motor strength and can perceive heat and cold in the feet. Report to the provider if block has not resolved within expected timeframe or if neurological recovery is asymmetric.

The complete clinical picture must be interpreted together. A respiratory rate of 14 breaths/min is above the minimum safe threshold of 12. Patellar reflexes of 1+ are diminished but present — loss of reflexes, not diminishment, signals toxicity. Flushing is an expected vasodilatory side effect of magnesium sulfate. Urine output of 28 mL/hr is just below the 30 mL/hr threshold and warrants provider notification and close monitoring, but it does not alone confirm toxicity requiring cessation of the infusion when all other parameters are acceptable.

Clinical pearl: Clinical Pearl: Magnesium toxicity assessment — hold the infusion for ANY of these: respiratory rate BELOW 12 (not just low — must be below 12), reflexes ABSENT (not just diminished — 1 plus is diminished but present and acceptable), or urine output below 25 to 30 mL per hour for two consecutive hours. One borderline value does not require stopping the infusion if other parameters are acceptable. Calcium gluconate administration is indicated for respiratory depression or absent reflexes — not for borderline urine output alone.