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","E"]
Explanation
The correct answer is choice A and E. The nurse should check the client’s blood pressure and magnesium level before giving hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
• Choice A is correct because hydralazine is an antihypertensive drug that lowers blood pressure by relaxing blood vessels.The nurse should monitor the client’s blood pressure before and after giving hydralazine to ensure that it is within the target range and to avoid hypotension or rebound hypertension.
• Choice B is wrong because pulse oximetry is not directly related to hydralazine administration or pre-eclampsia.Pulse oximetry measures the oxygen saturation of hemoglobin in the blood and can be affected by factors such as anemia, hypothermia, nail polish, or movement.
The nurse should monitor the client’s pulse oximetry as part of routine care, but it is not a priority before giving hydralazine.
• Choice C is wrong because checking the client’s reflexes is not directly related to hydralazine administration or pre-eclampsia.Reflexes are assessed to monitor for signs of magnesium toxicity, which can cause muscle weakness, respiratory depression, and cardiac arrest.
The nurse should check the client’s reflexes as part of routine care, but it is not a priority before giving hydralazine.
• Choice D is wrong because checking the client’s urine specific gravity is not directly related to hydralazine administration or pre-eclampsia.Urine specific gravity measures the concentration of solutes in the urine and can be affected by factors such as hydration status, renal function, or diuretic use.
The nurse should monitor the client’s urine specific gravity as part of routine care, but it is not a priority before giving hydralazine.
• Choice E is correct because magnesium sulfate is a drug that prevents and treats seizures in women with severe pre-eclampsia or eclampsia.The nurse should monitor the client’s magnesium level before and after giving magnesium sulfate to ensure that it is within the therapeutic range and to avoid magnesium toxicity.
Correct Answer is D
Explanation
“I should take a baby aspirin every day as prescribed.” Taking a baby aspirin daily has been shown to reduce the risk of developing preeclampsia by about 15%.If you have risk factors for preeclampsia, your healthcare provider may recommend starting aspirin in early pregnancy (by 12 weeks gestation).
Choice A is wrong because avoiding foods that are high in sodium does not prevent preeclampsia.Sodium intake does not affect blood pressure in pregnancy.
Choice B is wrong because lying on your left side for at least 2 hours a day does not prevent preeclampsia.However, lying on your left side may help improve blood flow to your placenta and your baby.
Choice C is wrong because checking your blood pressure at home every day does not prevent preeclampsia.However, monitoring your blood pressure at home may help detect signs of preeclampsia early and alert you to seek medical attention if needed.
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