The nurse is continuing to care for the client.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° F). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Day 1, 0930:. Oxygen saturation 97% on room air.
Temperature (oral) 37.1° C (98.8° F). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 99% on room air.
Drag words from the choices below to fill in each blank in the following.
sentence.
The client is at greatest risk for developing Target 1 and Target 2. Conditions.
Placental abruption.
Cervical insufficiency.
Seizures.
Hypoglycemia.
Heart failure.
Correct Answer : A,C
The correct answers are Choices A and C.
Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.
Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.
Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.
Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.
Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer is: a. "The estimated blood loss was 250 milliliters."
Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.
Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.
Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.
Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.
Correct Answer is B
No explanation
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