A nurse is caring for a client in the outpatient health clinic.

Exhibits
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Encourage naps during the day when client is tired.

Advise client to rise slowly from sitting position.

Instruct client to avoid foods that have been fermented or aged.

Encourage client to sleep until later in the morning.

Encourage a regular sleep-wake schedule.

Advise client to notify provider if pregnant.

Encourage high-calorie finger foods.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}

Rationale:

• Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep quality and reduce trazodone’s effectiveness in reestablishing a normal sleep pattern.

• Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension, particularly when therapy is initiated. Educating the client to change positions slowly helps prevent dizziness and potential falls caused by sudden drops in blood pressure.

• Instruct client to avoid foods that have been fermented or aged: This instruction applies to MAOIs due to the risk of hypertensive crisis from tyramine, but trazodone is a serotonin antagonist and reuptake inhibitor, not an MAOI.

• Encourage client to sleep until later in the morning: Oversleeping disrupts the circadian rhythm and may worsen fatigue. The goal is to maintain a stable sleep-wake cycle to enhance mood and energy regulation.

• Encourage a regular sleep-wake schedule: Establishing consistent sleep routines supports trazodone’s sedative effects and helps regulate the client’s circadian rhythm, improving overall sleep quality without disrupting normal activity patterns.

• Advise client to notify provider if pregnant: Trazodone is classified as pregnancy category C, meaning potential fetal risks exist. The client should notify the provider to evaluate the safety of continuing or adjusting medication during pregnancy.

• Encourage high-calorie finger foods: The client’s BMI has decreased, and trazodone may cause appetite suppression. Offering convenient, calorie-dense snacks helps maintain adequate nutrition and prevents further weight loss.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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

Explanation

Rationale for Correct Choices

• Seizures: The client’s BP of 166/110 mm Hg, +3 pitting edema, hyperreflexia (4+), and 3+ proteinuria are hallmark findings of severe preeclampsia, which places the client at high risk for progression to eclampsia (seizures). Cerebral edema and vasospasm associated with preeclampsia can precipitate convulsions if untreated.

• Placental abruption: Severe hypertension causes vasoconstriction and endothelial damage in uteroplacental vessels, predisposing the placenta to premature separation. This can lead to fetal distress, decreased movement, and potential maternal hemorrhage, both consistent with placental abruption risk in preeclampsia.

Rationale for Incorrect Choices

• Hypoglycemia: This condition is not related to preeclampsia; it more commonly occurs in clients with diabetes or from medication effects such as insulin overuse.

• Cervical insufficiency: This condition involves painless cervical dilation leading to preterm birth, unrelated to hypertension or proteinuria.

• Heart failure: Although hypertension increases cardiac workload, the current findings (normal heart rate, no dyspnea, clear lungs) do not indicate heart failure in this client.

A. Gently push the syringe plunger to administer medication. B. Dissolve the medications together. C. Flush the NG tube with 5 mL of cold tap water after administration. D. Add medication directly to the enteral feeding.

Correct Answer is A

Explanation

Rationale:
A. Gently push the syringe plunger to administer medication: Medications given via NG tube should be administered slowly and gently using a syringe to avoid tube damage, aspiration, or sudden changes in gastric pressure. This technique ensures safe and effective delivery of the medication.

B. Dissolve the medications together: Mixing multiple medications can cause chemical interactions or precipitation, which can block the NG tube or reduce medication efficacy. Each medication should be dissolved and administered separately.

C. Flush the NG tube with 5 mL of cold tap water after administration: Flushing is necessary to maintain tube patency, but 5 mL is insufficient for continuous feedings. Typically, 15–30 mL of warm or room-temperature water is used to prevent tube occlusion.

D. Add medication directly to the enteral feeding: Adding medication to the feeding can alter the composition, affect absorption, and create a risk for tube blockage. Medications should be given separately with flushing before and after administration.

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A nurse is caring for a client in the outpatient health clinic. Exhibits For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits Which of the following conditions is the client is at greatest risk for developing? Select all that apply

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

Explanation

A nurse is preparing to administer three medications to a client who is receiving continuous enteral feedings through an NG tube. Which of the following actions is appropriate for the nurse to take?

Correct Answer is A

Explanation

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A nurse is caring for a client in the outpatient health clinic.

Exhibits
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.