Try Naxlex NCLEX-RN (Free-Trial)

The nurse is continuing to care for the client.

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.

Administer betamethasone.

Give antihypertensive medication.

Monitor intake and output hourly.

Performa vaginal examination every 12 hr.

Obtain a 24-hr urine specimen

Provide a low-stimulation environment

Maintain bed rest

Answer and Explanation

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

A. Administer betamethasone: Betamethasone is indicated to promote fetal lung maturity in a client at 31 weeks gestation at risk for preterm delivery. Administering corticosteroids reduces neonatal complications and is appropriate for this high-risk pregnancy.

B. Give antihypertensive medication: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, which requires prompt management to prevent maternal complications such as stroke, eclampsia, or organ damage. Administering antihypertensives is a priority in controlling blood pressure.

C. Monitor intake and output hourly: Frequent monitoring of fluid balance is essential due to the risk of renal impairment from preeclampsia. Hourly intake and output helps detect oliguria or fluid retention, which can indicate worsening maternal status or impending complications.

D. Perform a vaginal examination every 12 hr: Routine vaginal examinations are avoided in clients with preeclampsia or severe hypertension due to the risk of inducing labor or causing trauma. Vaginal exams should be performed only when medically indicated.

E. Obtain a 24-hr urine specimen: Measuring proteinuria via a 24-hour urine collection helps evaluate the severity of preeclampsia and guides clinical management. This client has 3+ protein on urinalysis, confirming significant proteinuria.

F. Provide a low-stimulation environment: Reducing stimuli helps prevent exacerbation of headache, hypertension, and risk for seizures. A calm, quiet environment is a standard intervention for clients with severe preeclampsia.

G. Maintain bed rest: Bed rest with lateral positioning promotes uteroplacental perfusion, reduces blood pressure, and helps prevent complications such as eclampsia. The intervention supports maternal and fetal stability in the acute phase of severe preeclampsia.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "You should push the button before physical activity to allow maximum pain control.": Preemptively using the PCA before activities such as ambulation or physical therapy helps prevent breakthrough pain, allowing the client to perform activities more comfortably. This approach maximizes the effectiveness of pain control.

B. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels.": Continuous PCA is designed to maintain consistent plasma levels of medication, not fluctuating levels. This ensures steady pain control rather than peaks and troughs.

C. "You can adjust the amount of pain medication you receive by pushing on the keypad.": Clients cannot override the preset dosage limits on a PCA pump. The device is programmed by the healthcare provider to deliver safe doses, so self-adjusting the amount is not permitted.

D. "The PCA will deliver a double dose of medication when you push the button twice.": PCA pumps have lockout intervals to prevent overdosing. Pressing the button multiple times during the lockout period will not deliver extra doses, so this statement is incorrect and could be dangerous if misunderstood.

A. Refrain from using a tether strap on the car seat for children under 1 year of age. B. Manual shoulder belts in the front seat are acceptable for school-age children over 8 years of age. C. Restrict using rear-facing car seats for children after 1 year of age. D. Booster seats with belt-positioning should be used for school-age children until 8 years of age

Correct Answer is D

Explanation

A. Refrain from using a tether strap on the car seat for children under 1 year of age: Tether straps are generally used for forward-facing car seats to reduce forward movement in a crash. Infants under 1 year should be in rear-facing seats, where tethers are not typically applicable, but the focus should be on proper rear-facing installation rather than avoiding tethers altogether.

B. Manual shoulder belts in the front seat are acceptable for school-age children over 8 years of age: Children under 13 years should ride in the back seat whenever possible, as front-seat placement increases the risk of injury from airbags and seat belts. Using front seats is not recommended solely based on age.

C. Restrict using rear-facing car seats for children after 1 year of age: Current guidelines recommend keeping children in rear-facing seats as long as possible, typically until at least age 2 or until they reach the height and weight limits of the rear-facing seat. Restricting rear-facing use at 1 year is outdated and unsafe.

D. Booster seats with belt-positioning should be used for school-age children until 8 years of age: Booster seats help position the seat belt correctly over a child’s shoulder and lap, reducing the risk of injury in a crash. This is consistent with current safety guidelines and supports proper seat belt use until the child is tall enough and meets weight requirements for adult seat belts.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is continuing to care for the client. 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 providing preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is teaching a group of parents about car seat safety. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a 9-year-old child on the pediatric unit. Complete the following sentence by using the lists of options. The nurse should plan to _____ followed by _____ .

A nurse is assessing a client who is experiencing acute amphetamine toxicity. Which of the following findings should the nurse expect?

A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy. Complete the following sentence by using the lists of options. The child is at risk for developing _____ as evidenced by their _____ .

A nurse is caring for a client who has a new diagnosis of terminal advanced lung cancer. Which of the following is an expected stage of grief based on the stages of dying?

A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac disease. In which of the following positions should the nurse place the client to promote optimal cardiac output?

A nurse is planning care for multiple children on a pediatric unit who have gastroesophageal reflux. Which of the following children requires a revision to their plan of care?

A nurse is caring for an adolescent. Complete the following sentence by using the lists of options. The adolescent is at risk for developing _____ as evidenced by _____

A nurse is assessing a client who is using crutches as an assistive device due to a right hip fracture. Which of the following actions should the nurse take prior to planning the client's care?

The nurse is continuing to care for the client.

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.