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 A

Explanation

A. A client who has a prescription for compression stockings and did not receive them. B. A client who consumes all the food from their meal tray. C. A client who requests to sit in the bedside chair while watching TV. D. A client who requests assistance to use the bedside commode.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the assistive personnel (AP) to report the client who has a prescription for compression stockings but did not receive them. This situation involves a missed intervention that is crucial for the client's health and safety. Reporting this to the nurse allows timely intervention and ensures that the client receives the necessary care.

Choice B rationale:

Consuming all the food from the meal tray is not a cause for concern and does not require immediate reporting to the nurse. It is a normal behavior and does not indicate any potential issues with the client's health or safety.

Choice C rationale:

The client's request to sit in the bedside chair while watching TV is a common and appropriate request. It does not pose any risk to the client's health or safety and does not require immediate reporting to the nurse.

Choice D rationale:

A client requesting assistance to use the bedside commode indicates a need for assistance with a basic activity of daily living. The AP should assist the client with this request as appropriate and does not need to report it to the nurse unless complications or concerns arise during the process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship.Which of the following statements should the nurse make during this phase?

Correct Answer is A

Explanation

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.Which of the following clients should the nurse instruct the AP to report to the nurse?

Correct Answer is A

Explanation

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

A nurse is admitting a client to a medical-surgical unit.When performing medication reconciliation for the client, which of the following actions should the nurse take?

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago.Which of the following manifestations indicates that the client might be experiencing hypoglycemia?

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?