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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.

Give antihypertensive medication.

Perform a vaginal examination every 12 hr.

Provide a low-stimulation environment.

Administer betamethasone.

Obtain a 24-hr urine specimen.

Monitor intake and output hourly.

Maintain bed rest.

Answer and Explanation

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

The correct answers are Choices A, C, D, E, F, and G.

Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.

Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.

Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.

Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.

Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.

Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.

Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.

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Correct Answer is C

Explanation

Choice A rationale:

Heart rate 58/min. Clozapine, an atypical antipsychotic medication, can cause bradycardia (slow heart rate) as a side effect. However, the heart rate of 58/min is within the normal range for adults, so it is not a contraindication for clozapine administration.

Choice B rationale:

Fasting blood glucose 100 mg/dL. A fasting blood glucose level of 100 mg/dL is within the normal range (70-99 mg/dL) for adults. It is not a contraindication for clozapine administration.

Choice C rationale:

WBC count 2,900/mm3. Clozapine can cause agranulocytosis, a severe reduction in white blood cell (WBC) count, which can lead to increased susceptibility to infections. A WBC count of 2,900/mm3 is significantly below the normal range (4,000-11,000/mm3) and is a contraindication for clozapine administration due to the risk of severe immunosuppression.

Choice D rationale:

Hgb 14 g/dL. Hemoglobin (Hgb) level of 14 g/dL is within the normal range for adult males (13.8-17.2 g/dL) and females (12.1-15.1 g/dL). It is not a contraindication for clozapine administration.

A. A nurse expresses concern that another shift works fewer holiday hours. B. A nurse has a personal difficulty with caring for clients who have HIV. C. A nurse experiences insulting comments directed at them by another nurse. D. A nurse submits a complaint about another department's handoff reporting.

Correct Answer is C

Explanation

Choice A rationale:

Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.

Choice B rationale:

A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.

Choice C rationale:

Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.

Choice D rationale:

Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.

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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

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A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine.Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

Correct Answer is C

Explanation

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Correct Answer is C

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.