The nurse is continuing to care for the client.

Exhibits

Complete the following sentence by using the list of options

The provider has admitted the client to the inpatient obstetric unit and written prescriptions based on the client's condition.

The action the nurse should take first is
dropdown
followed by
dropdown
.

Answer and Explanation

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

Rationale for Correct Choices:

Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.

Rationale for Incorrect Choices:

Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. "I prefer to leave the lights off when I am changing my clothes.": This statement suggests discomfort with the appearance of the body after surgery and a desire to hide it, which reflects an altered body image. Avoiding visual exposure is a common coping mechanism for those struggling with physical changes.

B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group indicates acceptance and proactive coping. It reflects psychological adaptation rather than body image disturbance.

C. "I want to have reconstructive surgery as soon as I can.": Expressing a desire for reconstruction shows future-oriented thinking and a readiness to restore body image, not necessarily an inability to accept the current state.

D. "I understand that my scars will eventually fade.": This statement demonstrates acceptance and understanding of the healing process, indicating a realistic and healthy perception of body changes.

A. Blood pressure B. Syncope C. ECG D. Albumin

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Rationale:

A. Blood pressure: Orthostatic hypotension is evident from the drop in systolic and diastolic pressure when standing, indicating fluid and electrolyte imbalance. This may reflect volume depletion due to purging and requires monitoring to prevent fainting or falls.

B. Syncope: The client reports repeated fainting episodes, a red flag when paired with orthostatic hypotension and electrolyte disturbances. This suggests unstable cardiovascular status and raises the risk of injury or sudden cardiac events.

C. ECG: Sinus tachycardia with premature ventricular contractions indicates cardiac irritability likely due to electrolyte imbalance, especially hypokalemia. Continuous cardiac monitoring and correction of abnormalities are needed.

D. Albumin: An albumin level of 2.6 g/dL indicates significant malnutrition and protein deficiency, compromising immune function and wound healing. This also suggests a chronic issue requiring dietetic intervention and nutritional rehabilitation.

E. Potassium: Potassium at 3.0 mEq/L is dangerously low and a known contributor to cardiac arrhythmias and muscle weakness. Replenishment and close monitoring are critical to avoid complications such as cardiac arrest.

F. Sodium: Although sodium is only slightly low at 134 mEq/L, in the context of purging and poor intake, this could indicate dilutional hyponatremia. It increases seizure risk and needs assessment of fluid status and intake behaviors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

Correct Answer is A

Explanation

A nurse is caring for a client in an emergency department (ED).Exhibits Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?

A nurse is caring for a postpartum client in an outpatient setting. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdown evidenced by the client's dropdown.

A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?

A nurse is reviewing the BUN result of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory studies should the nurse recognize as another renal function study that should be monitored?

A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

A community health nurse is performing a home visit for a client and is evaluating the home environment for safety. Which of the following findings would indicate to the nurse that the client has a proper understanding of safety in the home?