The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.

Answer and Explanation

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

Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.

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Correct Answer is A

Explanation

A. Powered-standing assist lift: A powered-standing assist lift is appropriate for a cooperative client with upper body strength who is non-weight bearing. It allows the client to participate by supporting themselves with their arms while the device safely moves them from the bed to a chair without bearing weight on their lower extremities.

B. Draw sheet: A draw sheet is typically used for repositioning a client in bed, not for transferring them from bed to chair. It does not provide the mechanical support needed to lift and transfer a non-weight-bearing client safely.

C. Gait belt: A gait belt is useful for clients who can bear weight to some degree and require minimal assistance during transfers. Since this client is non-weight-bearing, a gait belt alone would not provide adequate support and could lead to injury.

D. Full body sling lift: A full body sling lift is used for clients who are non-weight bearing and lack the ability to assist in transfers. Since the client described here is cooperative and has upper body strength, a full sling would not be necessary and may restrict their participation.

A. Blood pressure B. Platelet count C. Alanine aminotransferase (ALT) D. Hemoglobin

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

Blood pressure: The client's significantly elevated blood pressure (162/112 mm Hg and 166/110 mm Hg) is characteristic of preeclampsia, which is defined by new-onset hypertension after 20 weeks of gestation. Hypertension is a major diagnostic criterion for preeclampsia but is not required for diagnosing HELLP syndrome.
Platelet count: The platelet count of 98,000/mm³ is lower than normal, supporting both preeclampsia and HELLP syndrome. In preeclampsia, thrombocytopenia can occur as the disease progresses, and in HELLP syndrome, low platelets are one of the triad components (Hemolysis, Elevated Liver enzymes, Low Platelet count).
Alanine aminotransferase (ALT): An ALT level of 40 Units/L is above the normal limit, indicating liver involvement. Elevated liver enzymes occur in both severe preeclampsia and HELLP syndrome, reflecting hepatic dysfunction or injury caused by systemic endothelial damage.
Hemoglobin: A hemoglobin of 18.0 g/dL is unusually high and suggests hemoconcentration, which is typical of preeclampsia due to fluid shifts out of the vascular space. In contrast, HELLP syndrome typically causes hemolysis leading to anemia, where hemoglobin would be expected to be low rather than elevated.

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfer a client who is non-weight bearing from the bed to a chair with the aid of an assistive personnel. The client is cooperative and has upper body strength. Which of the following assistive devices should the nurse use when transferring the client?

Correct Answer is A

Explanation

The nurse is reviewing the findings. For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.