The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing
dropdown
as evidenced by the client's
dropdown
.

Answer and Explanation

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

Rationale for Correct Options:

Preeclampsia is a hypertensive disorder of pregnancy that typically occurs after 20 weeks of gestation. This client has elevated blood pressure (156/96 mm Hg), proteinuria (25 mg/dL), hyperreflexia, headache, right upper quadrant pain, and facial edema—all hallmark signs of preeclampsia.
Urinalysis shows elevated protein, which is a diagnostic criterion for preeclampsia. Proteinuria is a result of kidney involvement due to endothelial damage from hypertension indicating kidney involvement due to the systemic vascular changes in preeclampsia.

Rationale for Incorrect Options:

Chorioamnionitis typically presents with maternal fever, uterine tenderness, foul-smelling amniotic fluid, and fetal tachycardia. This client is afebrile and has no signs of intrauterine infection.
Preterm labor is indicated by cervical changes and regular uterine contractions, neither of which are present. The fetal monitor shows no contractions, and there are no reports of vaginal drainage or pressure.
Serum WBC count is mildly elevated at 12,500/mm³, which can be normal in pregnancy and does not indicate infection or inflammation in this context.
Fundal assessment: The fundal height of 29 cm at 30 weeks is within the normal range (+/- 2 cm), so it does not evidence a particular risk.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

A. Wear a dosimeter film badge to measure exposure: The dosimeter badge tracks cumulative radiation exposure to ensure the nurse stays within safe limits. It is essential personal protective equipment when caring for clients undergoing internal radiation therapy.
B. Place a caution sign on the client’s door: A radiation warning sign alerts staff and visitors about the presence of a radioactive source, ensuring they follow safety protocols to minimize unnecessary exposure.
C. Discard bed linens from the client's room at the end of each day: Linens are not contaminated by a sealed implant, as the radiation source is enclosed and does not leak into the environment. Linens should be handled per routine procedure unless visibly soiled.
D. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should be instructed to stay at least 6 feet (approximately 183 cm) away and limit visits to 30 minutes. The 2-foot distance is insufficient to ensure safety from radiation exposure.
E. Don a lead apron when providing care: A lead apron helps shield the nurse from radiation exposure when close contact is necessary. It is a standard precaution when interacting with clients who have a sealed radiation source.

A. Measure the tubing from the nose to the distal port. B. Complete the feeding in 5 min. C. Warm the formula i n the microwave. D. Position the child at a 10o to 20o angle after feeding.

Correct Answer is A

Explanation

A. Measure the tubing from the nose to the distal port: Proper measurement of the NG tube ensures correct placement into the stomach. The usual method involves measuring from the tip of the nose to the earlobe and then to the xiphoid process, not to the distal port of the tube, but this choice most closely aligns with verifying safe tube length.
B. Complete the feeding in 5 min: Administering a feeding too quickly can cause abdominal cramping, vomiting, or aspiration. Feedings should be given slowly, typically over 15 to 30 minutes, depending on the child's tolerance and the volume.
C. Warm the formula in the microwave: Microwaving formula can cause uneven heating and result in hot spots that may burn the child’s mouth or GI tract. Formula should be warmed by placing the container in warm water and testing the temperature before administration.
D. Position the child at a 10° to 20° angle after feeding: This angle is too low and increases the risk of aspiration. The child should remain at a 30° to 45° angle for at least 30 minutes after feeding to promote digestion and prevent reflux.

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The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdownas evidenced by the client'sdropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing
dropdown
as evidenced by the client's
dropdown
.