Exhibits
The nurse is obtaining the client's vital signs prior to an endoscopy.
Complete the following sentence by using the list of options.
The nurse should first anticipate the need to
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
The nurse should first anticipate the need to Obtain IV access then Prepare to administer IV fluids.
Rationale
First Anticipated Step: Obtain IV Access:
In a client with hypotension and anemia, immediate IV access is crucial to administer fluids or blood
products to stabilize the client’s condition before the endoscopy. Given the client’s low blood pressure and heart rate, they may need IV fluids (such as saline or Ringer's lactate) to help improve circulation and maintain perfusion. This is essential before proceeding with further interventions like the planned endoscopy.
Second Anticipated Step:
Prepare to administer IV fluids:
The client's low blood pressure and the potential for significant blood loss suggest that IV fluids will be necessary to restore blood volume and improve hemodynamic stability before endoscopy. Normal saline or Lactated Ringer's are commonly used for volume resuscitation in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Smacking lips is a sign of tardive dyskinesia, not pseudoparkinsonism.
B. Serpentine limb movement is not a typical manifestation of pseudoparkinsonism.
C. Nonreactive pupils are not associated with pseudoparkinsonism but may be seen in other neurological conditions.
D. A shuffling gait is a classic manifestation of pseudoparkinsonism, a side effect of haloperidol (an antipsychotic medication).
Correct Answer is ["A","E"]
Explanation
A. Sepsis
Sepsis is a systemic infection that can occur during pregnancy, particularly if there is an infection such as chorioamnionitis (infection of the amniotic sac) or endometritis (infection of the uterine lining). The client's fever (38.4°C) could be indicative of infection, which is a risk factor for sepsis.
B. Placenta Previa
Placenta previa occurs when the placenta implants in the lower part of the uterus, covering the cervix. This can cause vaginal bleeding and may lead to complications during labor. However, this is not related to the client's current symptoms.
C. Disseminated Intravascular Coagulation (DIC)
DIC is a serious condition that can occur due to pregnancy complications like abruptio placentae, infection, or severe preeclampsia. However, the client’s symptoms do not indicate bleeding, bruising, or other signs of DIC. The client's blood pressure (130/78) is normal, and there are no indications of placental abruption.
D. Preeclampsia
Preeclampsia is characterized by hypertension and proteinuria. The client’s blood pressure (130/78) is normal, and there are no signs of significant swelling or other symptoms commonly associated with preeclampsia.
E. Preterm Premature Rupture of Membranes (PPROM)
PPROM is the rupture of the membranes (amniotic sac) before 37 weeks gestation, leading to the risk of infection, preterm labor, and other complications. While the client’s membranes are intact at this time, preterm labor at 33 weeks is a risk factor for PPROM.
F. Seizures
Seizures in pregnancy are most commonly seen in conditions like eclampsia, which is a complication of preeclampsia. However, the client does not have the signs of preeclampsia (high blood pressure, proteinuria, edema) that typically lead to eclampsia.
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