A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?
2+ pitting edema of the lower extremities
Increased hemoglobin
Blood pressure 158/54 mm Hg
Client report of upper right quadrant pain
The Correct Answer is D
Rationale:
A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.
B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.
C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.
D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Give the client several choices of foods for meals.": Providing multiple options can overwhelm a client with dementia and increase confusion or frustration. It is better to offer one or two simple choices to support decision-making without causing cognitive overload.
B. "Avoid making eye contact with the client.": Avoiding eye contact can appear dismissive or impersonal. Maintaining gentle eye contact helps establish trust, enhances communication, and can be grounding for clients who are cognitively impaired.
C. "Increase environmental stimuli”: A stimulating environment can lead to agitation or disorientation in clients with dementia. These clients benefit from calm, predictable surroundings with reduced noise, clutter, and distractions to support cognitive clarity.
D. "Label the door to the bathroom with a symbol.": Using clear labels or symbols helps orient clients with dementia and reduces confusion. Visual cues support recognition and promote independence in navigating their environment, especially with essential tasks like toileting.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.
• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.
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