The nurse is continuing to care for the client.

Exhibits

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 reflex response decreased from 4+ to 2+, demonstrating a reduction in hyperreflexia. This improvement indicates effective magnesium sulfate therapy, showing decreased neuromuscular irritability and a lower risk of progression to eclampsia.

• Blood pressure: The blood pressure declined from 166/110 mm Hg to 152/90 mm Hg, reflecting effective antihypertensive therapy and improved vascular tone. This moderate reduction suggests that labetalol and magnesium sulfate are successfully controlling severe preeclampsia symptoms.

• Heart rate: The heart rate remained within normal parameters (72–90/min) across both days, showing stable cardiac function without significant deviation. This consistency indicates no notable change in hemodynamic status related to treatment.

• Edema: The client continues to exhibit +3 pitting edema in both lower extremities, reflecting persistent fluid retention and endothelial dysfunction. This ongoing finding suggests that intravascular fluid shifts typical of preeclampsia have not yet resolved.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.

B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.

C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.

D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.

E. Infuse the blood over 4 hr: Each unit of packed RBCs should be transfused within no more than 4 hours to reduce the risk of bacterial contamination and hemolysis from prolonged infusion.

A. Monitor the IV site every 8 hours. B. Use gauze to cover the IV insertion site. C. Obtain a 24-gauge catheter. D. Insert the catheter into the foot.

Correct Answer is C

Explanation

Rationale:
A. Monitor the IV site every 8 hours: In infants, IV sites should be assessed much more frequently, typically every 1–2 hours, due to their fragile veins and higher risk of infiltration or phlebitis. Monitoring every 8 hours is insufficient for safety.

B. Use gauze to cover the IV insertion site: Transparent dressings are preferred for infants because they allow continuous visualization of the IV site for signs of infiltration, phlebitis, or infection. Gauze obscures the site and may delay detection of complications.

C. Obtain a 24-gauge catheter: A 24-gauge catheter is appropriate for peripheral IV access in infants. It is small enough to fit delicate veins while allowing adequate fluid and medication administration safely.

D. Insert the catheter into the foot: Foot veins are generally avoided in infants due to higher risk of complications and limited accessibility. Preferred sites include veins on the hands, forearms, or scalp, which are safer and easier to monitor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

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

Explanation

A nurse is preparing to insert a peripheral intravenous line on an infant. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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