A nurse is planning care for a client who is at 36 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse plan to implement?

Administer a continuous infusion of calcium gluconate

Place the client in the semi-Fowler's position.

Ensure bright lighting in the room.

Initiate seizure precautions.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Administer a continuous infusion of calcium gluconate: Calcium gluconate is not used for the management of preeclampsia or seizure prophylaxis. Magnesium sulfate is the medication of choice to prevent eclamptic seizures in clients with severe preeclampsia.

B. Place the client in the semi-Fowler's position: Semi-Fowler’s position does not optimize uteroplacental perfusion. Left lateral positioning is preferred to enhance blood flow to the uterus and improve maternal and fetal oxygenation.

C. Ensure bright lighting in the room: Bright lighting can increase stimulation and anxiety, which is not beneficial for a client at risk for seizures. A calm, low-stimulation environment is preferable to minimize seizure triggers.

D. Initiate seizure precautions: Clients with preeclampsia with severe features are at high risk for eclampsia, making seizure precautions essential. These include placing the bed in a low position, padding side rails, having oxygen and suction available, and monitoring closely for neurologic changes.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Change a dressing on an implanted central venous access device: This is a sterile procedure that requires assessment skills and knowledge of infection control. It must be performed by a licensed nurse, not an assistive personnel (AP).

B. Suction a new tracheostomy: Suctioning a new tracheostomy is a high-risk procedure requiring specialized knowledge to prevent hypoxia or trauma. Only a licensed nurse should perform this intervention.

C. Perform postmortem care: Postmortem care is within the scope of practice for an AP. It involves cleansing, positioning, and preparing the body for the family or mortuary, and does not require advanced clinical judgment or sterile technique.

D. Remove an NG tube: Removal of a nasogastric tube requires assessment and understanding of client tolerance and potential complications, which are responsibilities of a licensed nurse. It is not appropriate to delegate this task to an AP.

A. Restrict daily exercise B. Encourage 3 large meals per day. C. Limit dietary salt intake D. Obtain weight once per week.

Correct Answer is C

Explanation

Rationale:

A. Restrict daily exercise: Clients with heart failure benefit from regular, moderate activity as tolerated to improve cardiac efficiency and prevent deconditioning. Restricting all exercise can worsen functional status and is not recommended unless specifically limited by the healthcare provider.

B. Encourage 3 large meals per day: Large meals can increase cardiac workload and exacerbate heart failure symptoms due to increased blood flow demands during digestion. Smaller, more frequent meals are preferable to reduce strain on the heart.

C. Limit dietary salt intake: Reducing sodium intake helps prevent fluid retention and edema, which can exacerbate heart failure and increase cardiac workload. Teaching clients to limit salt is a key intervention to manage decreased cardiac output and maintain stable fluid balance.

D. Obtain weight once per week: Daily weight monitoring is recommended for clients with heart failure to detect fluid retention early. Weekly weights may delay recognition of sudden fluid accumulation, increasing the risk of decompensation.

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Body system	Findings
Neurologic	Client is awake, alert, oriented x3
Cardiovascular	Client reports no palpitations, heart rhythm regular. Right lower extremity +2 edema from ankle to below the knee joint. Skin warm and inflamed: +2 pedal pulses present in bilateral extremities
Musculoskeletal	Client reports no groin pain, has slight limp with weight bearing on the right extremity

A nurse is planning care for a client who is at 36 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse plan to implement?

Nursing Test Bank

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Explanation

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