A nurse is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse understands that the patient has likely developed

and will need to be monitored for ___
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}

Lithium toxicity: The client's lithium level is significantly elevated at 2.5 mEq/L (normal range is 0.6 to 1.2 mEq/L), and symptoms such as blurred vision, increased urine output, and clonic jerking of the upper extremities are indicative of lithium toxicity2.
Seizure activity: Lithium toxicity can lead to neurological symptoms, including seizures, which require close monitoring

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Correct Answer is ["A","E"]

Explanation

A. Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP): This action is not the priority in the context of the client's current clinical status, particularly with the risk of placental abruption and severe bleeding. Fetal monitoring via scalp electrode and IUCP is typically reserved for stable clients, and invasive monitoring should be avoided in a potentially unstable situation.

B. Obtain serial H&H and clotting studies: The client is presenting with significant vaginal bleeding, low hemoglobin (8.1 g/dL at 0930, decreased to 7.5 g/dL at 1005), and low hematocrit levels (24% at 0930, dropping to 21% at 1005). Serial hemoglobin and hematocrit levels will help monitor ongoing blood loss and guide decisions regarding further interventions, such as transfusion. Clotting studies, including the prothrombin time and PTT, are necessary to assess the client's coagulation status and potential for disseminated intravascular coagulation (DIC), which can be associated with placental abruption or severe bleeding.

C. Administer misoprostol 600 mg rectally: Misoprostol is used to manage postpartum hemorrhage or to induce labor, but it is not indicated in the acute management of this client's condition. The client is 38 weeks gestation and presenting with signs of potential placental abruption, not requiring the use of misoprostol at this time.

D. Place the client in a supine position: The client should not be placed in a supine position, as this may exacerbate hypotension due to the supine hypotension syndrome, particularly if the uterus is compressing the inferior vena cava. The client would benefit more from positioning that promotes circulation, such as lying on the left side.

E. Prepare to transfuse 2 units of packed RBCs: The client is showing signs of hypovolemic shock with progressively declining blood pressure (from 95/62 mm Hg to 85/48 mm Hg), elevated heart rate (from 104/min to 128/min), and worsening hematocrit and hemoglobin. Blood transfusion is likely necessary to restore circulating volume, improve oxygen delivery, and address the ongoing blood loss.

A. "Take an oral estrogen supplement." B. "Soak in a warm bath every day." C. "Empty your bladder every 6 hours." D. "Drink 2 liters of water per day."

Correct Answer is D

Explanation

A. Oral estrogen supplements may be used in postmenopausal women but are not the first-line preventative measure for UTIs.

B. Soaking in a warm bath can increase the risk of infection by introducing bacteria into the urethra.

C. Emptying the bladder every 6 hours is too infrequent; voiding every 2-4 hours is recommended to prevent urinary stasis.

D. Adequate hydration flushes the urinary system, reducing the risk of bacterial growth and recurrent infections.

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A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed ______ and will need to be monitored for _________.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Select the 2 actions that the nurse should take.

Correct Answer is ["A","E"]

Explanation

A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?

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A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take?

A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in- service? (Select all that apply.)

A nurse is caring for a 9-year-old child at a clinic. Exhibits A nurse is continuing to care for the child. Complete the following sentence by using the lists of options. The child is at highest risk for developing ___1___ as evidenced by the child's ___2____.

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A nurse is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse understands that the patient has likely developed

and will need to be monitored for ___
.