A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion.
What nursing interventions are appropriate for this client? Select all that apply.
Monitor vital signs and urine output
Administer corticosteroids as prescribed
Check for signs of fluid overload or transfusion reaction
Encourage oral intake of fluids and electrolytes
Maintain bed rest and a quiet environment
Correct Answer : A,C
The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction. Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure. The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.
Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity. Corticosteroids may worsen the liver function and increase the risk of infection.
Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome. Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.
Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome. The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible. Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client has no seizures or eclampsia.This outcome would indicate that the magnesium sulfate therapy is successful because magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.
Some additional information for the other choices are:
• Choice B. The client delivers a healthy baby vaginally.
This outcome is desirable but not directly related to the effectiveness of magnesium sulfate therapy.Magnesium sulfate can help prolong a pregnancy for up to two days to allow drugs that speed up the baby’s lung development to be administered, but it does not guarantee a vaginal delivery or a healthy baby.
• Choice C. The client has normal blood pressure and urine output.
This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.
Magnesium sulfate may help reduce blood pressure in some cases, but it is not the primary treatment for hypertension in preeclampsia.Other medications such as antihypertensives are usually prescribed for that purpose.Urine output should be monitored closely while receiving magnesium sulfate therapy, as a decrease may indicate toxicity or kidney impairment.Urine output should be at least 30 mL/hour while administering magnesium sulfate.
• Choice D. The client has improved liver function and platelet count.
This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.
Magnesium sulfate does not affect liver function or platelet count in preeclampsia.These parameters may improve after delivery of the placenta, which is the main cause of preeclampsia.
Normal ranges for blood pressure, urine output, liver function and platelet count are:
• Blood pressure: less than 140/90 mm Hg
• Urine output: at least 30 mL/hour
• Liver function: AST and ALT less than 40 U/L, LDH less than 600 U/L, bilirubin less than 1.2 mg/dL
• Platelet count: 150,000 to 450,000 per microliter of blood
Correct Answer is A
Explanation
Hydralazine can causetachycardia(fast heart rate) as a common side effect.
This is because hydralazine lowers blood pressure by relaxing blood vessels, which can make the heart beat faster to compensate.
Choice B is wrong because hydralazine does not causehyperglycemia(high blood sugar).
Hydralazine is not known to affect glucose metabolism or insulin secretion.
Choice C is wrong because hydralazine does not causehypokalemia(low potassium levels).
Hydralazine is not a diuretic and does not increase potassium excretion.
Choice D is wrong because hydralazine does not causeconstipation.Hydralazine can causediarrheaas a common side effect, but not constipation.
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