The nurse is continuing to care for the client.

Nurses' Notes.

Day 1, 0900:. Day 1, 0930:. Client is at 31 weeks of gestation and presents with a severe.

headache unrelieved by acetaminophen.

Client also reports.

urinary frequency and decreased fetal movement.

Client is a G3. P2 with one preterm birth.

Client reports a constant and throbbing headache and rates it. as a 6 on a scale of 0 to 10. Denies visual disturbances.

+3. pitting edema in bilateral lower extremities.

Patellar reflex 4+. without the presence of clonus.

Client reports occasional.

nighttime leg cramps.

Reports three fetal movements within the.

last 30 min.

External fetal monitor applied with a baseline FHR.

140/min with occasional accelerations and moderate variability.

No uterine contractions noted.

Vital Signs.

Day 1, 0900:. Temperature (oral) 36.9° C (98.4° ). Heart rate 72/min.

Respiratory rate 16/min.

BP 162/112 mm Hg. Oxygen saturation 979% on room air.

Day 1, 0930:. Temperature (oral) 37.1° C (98.8° ). Heart rate 84/min.

Respiratory rate 18/min.

BP 166/110 mm Hg. Oxygen saturation 999% on room air.

Color yelow yelow). pH 5.9 (4.6 to 8). Protein 3+ (negative). Specific gravity 1.013 (1.005 to 1.03). Leukocyte esterase negative (negative). Nitrites negative (negative). Ketones negative (negative). Crystals negative (negative). Casts negative (negative). Glucose trace (negative). WBC 5 (0 to 4). WBC casts none (none). RBC 1 (less than or equal to 2). RBC casts none (none). Day 1, 1030:. CBC:. Hemoglobin 18.0 g/dL (12 to 16 g/dL). Hematocrit 35% (37 to 479%). Platelets 98,000/mm³ (150,000 to 400,000/mm³). BUN 19 mg/dL (10 to 20 mg/dL). Creatinine 0.8 mg/dL (0.5 to 1 mg/d). WBC 8,000/mm³ (5,000 to 10,000/mm³). Glucose 85 mg/dL (74 to 106 mg/dL). Liver Enzymes:. Alanine aminotransferase (ALT) 40 units/L (4 to 36 units/L). Aspartate aminotransferase (AST) 42 units/L (0 to 35 units/L). Total bilirubin 1.2 mg/dL (0.3 to 1 mg/dL). 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.

Platelet count

Hemoglobin

Alanine aminotransferase (ALT)

Blood pressure

Answer and Explanation

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

Nursing Test Bank

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Correct Answer is C

Explanation

The correct answer is choiceC. “Have your child drink a small glass of water after swallowing the medication.”

Choice A rationale:

Adding digoxin to a half-cup of juice is not recommended because it can affect the absorption of the medication.It is best to give digoxin on an empty stomach or with a small amount of food if necessary.

Choice B rationale:

Limiting potassium intake is incorrect.In fact, maintaining adequate potassium levels is important because low potassium levels can increase the risk of digoxin toxicity.

Choice C rationale:

Having the child drink a small glass of water after taking the medication helps ensure that the medication is swallowed completely and reduces the risk of esophageal irritation.

Choice D rationale:

Repeating the dose if the child vomits within 1 hour is not recommended. If a dose is vomited, it should not be repeated to avoid the risk of overdose.The next dose should be given at the regular scheduled time.

A. Draw blood specimens for culture and sensitivity. B. Obtain a CBC with differential. C. Transport the client to radiology for a CT scan. D. Administer nitroglycerin 0.4 mg SL 30 min before the procedure.

Correct Answer is B

Explanation

The correct answer is choiceb. Obtain a CBC with differential.

Choice A rationale:

Drawing blood specimens for culture and sensitivity is not typically required before a cardiac catheterization unless there is a specific concern about infection.

Choice B rationale:

Obtaining a CBC with differential is important to assess the client’s overall health and detect any potential issues such as anemia or infection that could complicate the procedure.

Choice C rationale:

Transporting the client to radiology for a CT scan is not a standard pre-procedure task for cardiac catheterization. This might be necessary if there are specific indications, but it is not routine.

Choice D rationale:

Administering nitroglycerin 0.4 mg SL 30 minutes before the procedure is not a standard practice for preparing a client for cardiac catheterization.Nitroglycerin is typically used to manage chest pain or angina, not as a pre-procedure medication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure?

Correct Answer is B

Explanation

A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?

A nurse is planning care for a client who has acute appendicitis.Which of the following actions should the nurse plan to take?

A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hr ago. Which of the following findings reported by the parent is the nurse's priority?

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care?

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?