The nurse is continuing to care for the client.

Exhibits

The nurse is reviewing the assessment findings.

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

Blood pressure

Elevated alanine aminotransferase (ALT)

Platelet count

Hemoglobin

Answer and Explanation

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

Finding	Preeclampsia	HELLP syndrome
Blood pressure	✓	✓
Elevated alanine aminotransferase (ALT)		✓
Platelet count		✓
Hemoglobin		✓

Rationale:

Preeclampsia: Characterized by hypertension and proteinuria.

HELLP syndrome: A severe form of preeclampsia, characterized by hemolysis, elevated liver enzymes (ALT, AST), and low platelet count.

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Correct Answer is D

Explanation

A. Monitoring every 30 minutes is insufficient; it should be more frequent.

B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.

C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.

D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.

A. "There was a total of 10 sponges used during the procedure." B. "The client was intubated without complications." C. "The estimated blood loss was 250 milliliters." D. "The client is a member of the board of directors."

Correct Answer is C

Explanation

A. The number of sponges used during surgery is important but does not provide as much relevant information for postoperative care.

B. The intubation status is relevant to the immediate perioperative period, but the primary concern in hand-off is the current postoperative condition.

C. Estimated blood loss is an important clinical detail to convey during hand-off, as it may impact the client's recovery and need for monitoring.

D. The client’s position or professional role (e.g., being a board member) is not relevant to the care plan and should not be included in the hand-off report.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is C

Explanation

A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A nurse is consulting a pharmacological reference about medication compatibility prior to administering warfarin to a client. Which of the following medications should the nurse identify as being incompatible with warfarin?

A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

A nurse is caring for a client in an outpatient clinic. Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

The nurse is continuing to care for the client.

Exhibits

The nurse is reviewing the assessment findings.

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