A nurse is caring for a client who is pregnant.

Exhibits

A nurse is evaluating the client's response to therapy. Which of the following recent assessment findings indicate the client's condition has improved or not changed?

For each recent assessment finding. click to specify if the finding indicates the client’s condition has improved or has not changed. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Deep tendon patellar reflex

Blood pressure

Edema

Heart rate

Answer and Explanation

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

Deep tendon patellar reflex (DTR): The client’s reflexes decreased from 4+ on Day 1 to 2+ on Day 2. Hyperactive reflexes are a hallmark of preeclampsia with severe features, so the reduction indicates an improvement in neuromuscular excitability.

Blood pressure: While slightly decreased from 166/110 mm Hg (Day 1, 0930) to 152/90 mm Hg (Day 2, 0900), indicating partial improvement with antihypertensive therapy. However, the BP remains elevated above normal range requiring further management.

Heart rate: The heart rate changed from 84–90/min (Day 1–Day 2), which is stable and within normal limits, suggesting no acute cardiovascular compromise.

Edema: The client continues to have +3 pitting edema in bilateral lower extremities on both Day 1 and Day 2, showing no change in fluid retention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale:

The client is postpartum day 3 after a cesarean birth with prolonged rupture of membranes, which increases the risk for uterine infection. Findings of boggy uterus initially, tenderness, and moderate, foul-smelling lochia indicate inflammation or infection of the endometrium. The elevated WBC count (33,000/mm³) and low-grade fever support an infectious process. Although the client also has firm, warm breasts, this alone is consistent with normal lactation or early engorgement; the systemic signs and uterine findings point more strongly to endometritis.

A. Creatinine B. Bilirubin C. Amylase D. Alkaline phosphatase

Correct Answer is A

Explanation

A. Creatinine is a key indicator of kidney function. Elevated serum creatinine levels suggest impaired renal filtration, which is a potential adverse effect of cyclosporine (a nephrotoxic immunosuppressant). Monitoring both BUN and creatinine provides a comprehensive view of renal health.

B. Bilirubin reflects liver function, not renal function.

C. Amylase assesses pancreatic activity, useful for diagnosing pancreatitis, not kidney function.

D. Alkaline phosphatase (ALP) indicates liver or bone disorders, unrelated to renal function monitoring.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is likely experiencing dropdown as evidenced by the client’s dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse is reviewing the BUN result of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory studies should the nurse recognize as another renal function study that should be monitored?

Correct Answer is A

Explanation

A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?

A nurse is caring for a client who has an allergy to penicillin. The health care provider has prescribed amoxicillin. Which of the following actions should the nurse take?

A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply

A nurse is providing discharge teaching to a new parent about breastfeeding her infant. Which of the following statements should the nurse make?

The nurse is continuing to care for the client. Exhibits The nurse is initiating the client’s plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?