A nurse is providing phone advice for a client who is pregnant.
Complete the following sentence by using the copy pasting from the list of options.
The client is at risk for experiencingelectrolyte imbalancedue to the
The Correct Answer is {"dropdown-group-1":"C"}
Electrolyte imbalance in pregnant clients is often associated with conditions that lead to dehydration and nutritional deficiencies. In this scenario, the key indicators are persistent nausea and significant weight loss.
- Persistent nausea can lead to reduced food and fluid intake. This condition, especially if prolonged, can cause dehydration and electrolyte imbalances due to the loss of essential minerals and nutrients that are not being replenished due to inadequate dietary intake.
- Significant weight loss, particularly the amount described in the scenario (6.8 kg or 15 lb), is a clear sign of inadequate nutritional intake and can further exacerbate the risk of electrolyte imbalance. It indicates that the body is not receiving enough nutrients, which is crucial for maintaining electrolyte balance.
The other options, while related to diet and fluid intake, are more specific to the client's eating habits and do not directly point to the primary cause of potential electrolyte imbalance in the context of this scenario. Therefore, the most comprehensive and medically relevant choice is (A) Persistent nausea and significant weight loss.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.
- B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.
- C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.
- D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should ensure that the side rails are up on the client's bed. This action is essential for the safety of the client with severe preeclampsia, as it prevents accidental falls or injuries. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and signs of organ damage, and it poses significant risks to both the mother and the fetus. By keeping the side rails up, the nurse can minimize the risk of falls and ensure the client's safety while in bed.
Choice B rationale:
Ambulating the client every 4 hours is not appropriate for a pregnant woman with severe preeclampsia. Preeclampsia can cause high blood pressure, swelling, and proteinuria. It is a serious condition that requires close monitoring and strict bed rest to prevent complications such as seizures or eclampsia. Ambulation may increase the risk of falls and is contraindicated in this situation.
Choice C rationale:
Checking the fetal heart rate twice daily is important in the care of a pregnant client with severe preeclampsia. However, ensuring the client's safety by keeping the side rails up on the bed takes priority. While monitoring the fetal heart rate is crucial for assessing the baby's well-being, it does not address the immediate safety concerns of the client, which can be addressed by maintaining the side rails up.
Choice D rationale:
Providing the client with a low-protein diet is not the correct action for a pregnant woman with severe preeclampsia. In fact, pregnant women with preeclampsia are often advised to increase their protein intake to help manage their condition. A low-protein diet can lead to malnutrition and may not provide the necessary nutrients for both the mother and the developing fetus. The primary focus should be on bed rest, monitoring vital signs, and managing symptoms to prevent complications.
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