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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Perform a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Administer betamethasone.

Monitor intake and output hourly.

Give antihypertensive medication.

Provide a low-stimulation environment

Maintain bed rest.

Answer and Explanation

Correct Answer : B,C,E,F,G

A. Perform a vaginal examination every 12 hr. Routine vaginal examinations are not indicated at this stage of care, as there are no signs of labor or uterine contractions. Vaginal exams should only be performed if there are indications of preterm labor or changes in maternal symptoms.

B. Obtain a 24-hr urine specimen. Collecting a 24-hour urine specimen allows for accurate measurement of total protein excretion, which is critical for confirming the severity of preeclampsia. This diagnostic tool helps guide further management decisions.

C. Administer betamethasone. Betamethasone is given to promote fetal lung maturity in the event of a preterm delivery, which is a significant risk at 31 weeks of gestation in the presence of severe preeclampsia. It reduces neonatal morbidity and mortality.

D. Monitor intake and output hourly. While monitoring fluid status is essential, hourly monitoring is not typically required unless there are signs of worsening renal function, oliguria, or fluid imbalance. Regular but less frequent monitoring is sufficient for this client.

E. Give antihypertensive medication. The client's blood pressure readings of 162/112 mm Hg and 166/110 mm Hg require prompt antihypertensive treatment to reduce the risk of complications such as stroke, placental abruption, or eclampsia.

F. Provide a low-stimulation environment. A quiet, low-stimulation environment helps reduce the risk of seizures, which is a concern for clients with severe preeclampsia. This intervention supports neurological stability.

G. Maintain bed rest. Bed rest minimizes physical exertion, helping to lower blood pressure and improve placental perfusion, which is critical for fetal well-being in a client with severe preeclampsia.

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Correct Answer is D

Explanation

A. Lisinopril: Incorrect. Lisinopril, an ACE inhibitor, does not have a significant interaction with warfarin.

B. Magnesium hydroxide: Incorrect. While magnesium hydroxide can affect absorption of some drugs, it does not directly interact with warfarin in a significant manner.

C. Propranolol: Incorrect. Propranolol, a beta-blocker, does not have a significant interaction with warfarin.

D. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that increases the risk of bleeding when taken with warfarin due to its antiplatelet effects.

A. Ecchymosis B. Pain level C. Edema D. Sensation

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

Explanation

Assessment Findings	Sprain	Fracture	Dislocation
Ecchymosis	✅	✅	✅
Pain level	✅	✅	✅
Edema	✅	✅	✅
Sensation	✅	✅

Rationale:

Ecchymosis (bruising):

Sprain: Common due to soft tissue damage.

Fracture: Frequently present due to bone and soft tissue injury.

Dislocation: Bruising often accompanies joint dislocation.

Pain level:

Sprain: Moderate pain, often exacerbated by movement.

Fracture: Pain is typically sharp and worsens with movement or weight-bearing.

Dislocation: Severe pain due to misalignment of the joint.

Edema:

Sprain: Common due to inflammation from ligament injury.

Fracture: Swelling is typical around the fracture site.

Dislocation: Edema occurs due to joint misalignment and tissue trauma.

Sensation (tingling):

Sprain: Nerve compression or irritation may cause tingling.

Fracture: Tingling can result from nerve involvement or swelling near the fracture site.

Dislocation: Tingling is less common unless nerve damage occurs, which is more serious and often leads to numbness or motor impairment.

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The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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

Explanation

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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.