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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Correct Answer is A

Explanation

A. Place the cap from the solution sterile side upon a clean surface: The sterile side of the solution cap must be placed on a clean, dry surface to maintain its sterility. This prevents contamination of the solution during use, which is critical for infection control during dressing changes.
B. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: The outer 1–2 inches of a sterile field are considered contaminated, so placing items too close to the edge risks contamination. All sterile supplies should be placed well within the sterile field boundaries.
C. Set up the sterile field 5 cm (2 in) below waist level: Setting up below waist level increases the risk of contamination from clothing or accidental contact. The sterile field should always be at or above waist level to maintain sterility.
D. Open the outermost flap of the sterile kit toward the body:Opening the outer flap toward the body forces the nurse to reach over the sterile field, increasing the chance of contamination. It should be opened away from the body for safety.

A. Rotate staff members caring for the client. B. Speak in a neutral tone when addressing the client. C. Limit the clients opportunities to socialize with others. D. Mix the medication with the client's food items.

Correct Answer is B

Explanation

A. Rotate staff members caring for the client: Consistency in caregivers helps build trust in clients with paranoid personality disorder. Frequent changes in staff can increase suspicion and worsen paranoia, making care more difficult.
B. Speak in a neutral tone when addressing the client: A neutral, calm, and non-threatening tone helps avoid triggering the client’s mistrust or defensiveness. Clear and straightforward communication is essential for maintaining therapeutic rapport.
C. Limit the clients opportunities to socialize with others: Social interaction, when appropriate and safe, can help reduce isolation. Restricting social opportunities without cause can reinforce paranoid ideation and hinder recovery.
D. Mix the medication with the client's food items: Covertly administering medication violates client autonomy and can intensify paranoia if discovered. Informed consent and transparent communication are essential in psychiatric care.

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Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

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 preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Correct Answer is A

Explanation

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is planning care for assigned clients. Which of the following actions should the nurse plan to take to demonstrate effective time management?

A nurse is providing teaching about the use of metered-dose inhalers to a client who has asthma. Which of the following instructions should the nurse include?

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

A nurse is providing teaching to a client who has gastritis. Which of the following instructions should the nurse include in the teaching?

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?

A nurse is preparing to administer levothyroxine 50 mcg to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. use a leading zero if it applies. Do not use a trailing zero.)

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
.