The nurse is continuing to care for the client.

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed?

For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Deep tendon patellar reflex

Heart rate

Blood pressure

Edema

Answer and Explanation

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

Rationale:

• Deep tendon patellar reflex: The client’s patellar reflex decreased from 4+ on day 1 to 2+ on day 2, indicating reduced hyperreflexia. This suggests a positive response to antihypertensive and preeclampsia management, lowering the risk for complications such as eclampsia or seizures.

• Heart rate: The client’s heart rate increased slightly from 84/min on day 1 to 90/min on day 2, which falls within a normal physiologic range and does not indicate significant improvement or deterioration. This shows that cardiovascular status has remained relatively stable.

• Blood pressure: Blood pressure decreased from severely elevated readings (162/112 mm Hg and 166/110 mm Hg) to 152/90 mm Hg, reflecting a partial response to antihypertensive therapy. Although still above normal, the downward trend indicates some improvement in maternal hemodynamic status.

• Edema: The client continues to have +3 pitting edema in bilateral lower extremities, which has not improved since the previous day. Persistent edema suggests that fluid balance and vascular permeability issues related to preeclampsia remain a concern and require ongoing monitoring.

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Free Nursing Study Resources

Correct Answer is ["1.5"]

Explanation

Calculation:

Identify the ordered dose and available concentration

Ordered Dose: 30 mg

Available Concentration: 100 mg/5 mL

Calculate the volume to administer

Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration

Volume to administer = (30 ÷ 100) × 5

Volume to administer = 0.3 × 5

Volume to administer = 1.5 mL

A. "Your device is set to allow you to deliver small doses more frequently." B. "Using this device allows you to use less medication than other methods." C. "Your family member can push the PCA button for you if you're sleeping" D. "You will need to keep track of each dose you administer to avoid taking too much."

Correct Answer is A

Explanation

A. "Your device is set to allow you to deliver small doses more frequently.": PCA (patient-controlled analgesia) allows the client to self-administer small, controlled doses of pain medication as needed. This statement accurately explains how the device works and emphasizes client control within safe limits.

B. "Using this device allows you to use less medication than other methods.": While PCA can improve pain management, it does not necessarily reduce the total amount of medication used. The primary benefit is timely pain relief and maintaining therapeutic levels, not automatically using less medication.

C. "Your family member can push the PCA button for you if you're sleeping": Only the client should activate the PCA device to prevent overdose. Allowing others to push the button, a practice called “PCA by proxy,” is unsafe and can lead to serious complications.

D. "You will need to keep track of each dose you administer to avoid taking too much.": The PCA device is programmed with safety limits, including lockout intervals, to prevent overdose. The client does not need to manually track doses, as the device automatically controls and records administration.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer morphine 30 mg oral suspension to a client. The amount available is morphine 100 mg/5mL oral solution. How many mi should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.5"]

Explanation

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Correct Answer is A

Explanation

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