Exhibits

The client is at risk of developing
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Answer and Explanation

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

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Confusion can occur with electrolyte imbalances, including hyperkalemia, but it is not the most common or specific symptom associated with elevated potassium levels. More typical symptoms are related to muscle and gastrointestinal function.
B. Abdominal cramps are a common finding in clients with hyperkalemia (potassium level of 5.8 mEq/L). Elevated potassium can lead to increased gastrointestinal motility and irritability, resulting in symptoms such as abdominal cramps and diarrhea.
C. Positive Chvostek's sign indicates hypocalcemia (low calcium levels) and is not associated with hyperkalemia. This sign reflects increased neuromuscular excitability due to low calcium levels, so it would not be expected in this scenario.
D. Decreased bowel motility is typically associated with hypokalemia (low potassium levels) rather than hyperkalemia. Elevated potassium levels can cause increased bowel motility and may lead to gastrointestinal symptoms like diarrhea and cramping. Therefore, decreased bowel motility would not be an expected finding in this case.

A. Apply a warm pack to the client's puncture site. B. Monitor for bleeding at the catheter site. C. Replace the client's pressure dressing in 2 hr. D. Encourage the client to ambulate in 1 hr.

Correct Answer is B

Explanation

A. Apply a warm pack to the client's puncture site. Applying a warm pack to the puncture site is not appropriate immediately following cerebral angiography. Cold compresses are generally recommended initially to reduce swelling and discomfort, while warmth may be used later as advised by the healthcare provider.
B. Monitor for bleeding at the catheter site. Monitoring for bleeding at the catheter site is a critical action after cerebral angiography. The nurse should assess the site frequently for signs of hematoma or excessive bleeding, which can indicate complications from the procedure.
C. Replace the client's pressure dressing in 2 hr. The pressure dressing should not be replaced without specific orders from the healthcare provider. The nurse should assess the dressing for any signs of bleeding or drainage and follow the protocol for dressing changes as indicated.
D. Encourage the client to ambulate in 1 hr. Early ambulation may not be safe immediately after cerebral angiography, especially if the client has undergone a procedure involving sedation or if there is a risk of complications. The nurse should follow the provider's orders regarding activity restrictions and assess the client's readiness for ambulation based on their condition and vital signs.

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Exhibits The client is at risk of developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is reviewing a client's laboratory results. The client's potassium level is 5.8 mEq/L (3.5 to 5 mEq/L). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is assisting in the care of a client. Exhibits Which of the following interventions should the nurse plan to implement? Select all that apply.

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

A nurse is assisting with the care of a client. Exhibits Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

Exhibits

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