The nurse is reviewing the findings.

For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Blood pressure

Platelet count

Alanine aminotransferase (ALT)

Hemoglobin

Answer and Explanation

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

Blood pressure: The client's significantly elevated blood pressure (162/112 mm Hg and 166/110 mm Hg) is characteristic of preeclampsia, which is defined by new-onset hypertension after 20 weeks of gestation. Hypertension is a major diagnostic criterion for preeclampsia but is not required for diagnosing HELLP syndrome.
Platelet count: The platelet count of 98,000/mm³ is lower than normal, supporting both preeclampsia and HELLP syndrome. In preeclampsia, thrombocytopenia can occur as the disease progresses, and in HELLP syndrome, low platelets are one of the triad components (Hemolysis, Elevated Liver enzymes, Low Platelet count).
Alanine aminotransferase (ALT): An ALT level of 40 Units/L is above the normal limit, indicating liver involvement. Elevated liver enzymes occur in both severe preeclampsia and HELLP syndrome, reflecting hepatic dysfunction or injury caused by systemic endothelial damage.
Hemoglobin: A hemoglobin of 18.0 g/dL is unusually high and suggests hemoconcentration, which is typical of preeclampsia due to fluid shifts out of the vascular space. In contrast, HELLP syndrome typically causes hemolysis leading to anemia, where hemoglobin would be expected to be low rather than elevated.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Limit periods of sitting in a chair to 4 hr: Clients with urinary incontinence should avoid prolonged sitting because it increases pressure on the skin and raises the risk of skin breakdown. Sitting should be limited to shorter periods with frequent repositioning to protect skin integrity.

B. Avoid the use of draw sheets for repositioning: Draw sheets are helpful for repositioning clients safely and reducing friction and shear forces on the skin. Avoiding their use would increase the risk of skin injury, especially in clients with incontinence who are already vulnerable.

C. Use a no-rinse perineal cleanser after incontinence: Using a no-rinse perineal cleanser helps maintain skin hygiene, removes urine and feces gently, and prevents irritation or breakdown. It is an important part of incontinence care to protect the client's skin health.

D. Keep the head of the client's bed elevated to 45º: Elevating the head of the bed to 45º degrees is helpful for respiratory support but does not directly address urinary incontinence. Bed positioning should be adjusted based on overall client needs, not specifically to manage incontinence.

A. Auscultate the client's lung sounds B. Check the client's weight. C. Check the client's apical pulse. D. Obtain the client's oxygen saturation

Correct Answer is C

Explanation

A. Auscultate the client's lung sounds: While lung sounds are important to assess in clients with heart failure, auscultating lung sounds is not directly required before administering digoxin. The immediate concern with digoxin is its effect on heart rate and rhythm.

B. Check the client's weight: Monitoring weight is important in heart failure management to assess fluid retention, but weight measurement is not necessary immediately prior to administering a dose of digoxin.

C. Check the client's apical pulse: Before giving digoxin, it is critical to assess the client's apical pulse for one full minute. If the pulse is below a specified rate (60 beats/min for adults), the dose may need to be withheld and the provider notified due to the risk of digoxin-induced bradycardia.

D. Obtain the client's oxygen saturation: Oxygen saturation is important in evaluating respiratory function, but it is not a priority action before administering digoxin. The primary safety check is heart rate assessment.

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The nurse is reviewing the findings. For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the take prior to administering this medication?

Correct Answer is C

Explanation

A nurse is caring for a client who states, "I don't want to start dialysis treatments." Which of the following responses should the nurse make?

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

A nurse is reinforcing teaching about anorexia with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a 2-year-old male client. The parent states, "He has started playing with dolls since our baby was born. Does this indicate he will identify as a female as he grows up?" Which of the following responses should the nurse make?

A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client in a provider's clinic. For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

A nurse is discussing informed consent with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

The nurse is reviewing the findings.

For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.