A nurse in an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?
A client who is at 34 weeks of getation and reports double vision
A client who is at 38 weeks of gestation and reports leg cramps
A client who is at 8 weeks of gestation and reports excessive salivation
A client who is at 24 weeks of gestation and reports periodic finger numbness
The Correct Answer is A
A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension, so it does not cause hypertension. Instead, it lowers blood pressure.
B. Dizziness is a common adverse effect of losartan due to its blood pressure-lowering effects, which can lead to orthostatic hypotension.
C. Double vision is not a known adverse effect of losartan.
D. Losartan does not cause hyperactivity; it is more likely to cause fatigue or weakness.
Correct Answer is C
Explanation
A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.
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