When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
When the client has ankle edema.
If the client has an elevated blood pressure.
During admission to labor and delivery.
Within the first trimester of pregnancy.
The Correct Answer is B
Choice A reason: When the client has ankle edema, it is important for the nurse to assess for other signs of fluid retention, such as weight gain, jugular venous distension, and crackles in the lungs. However, ankle edema alone is not a specific indicator of preeclampsia or eclampsia, which are conditions that can cause hyperreflexia or increased DTRs.
Choice C reason: During admission to labor and delivery, it is important for the nurse to assess various aspects of the client's health status, such as vital signs, fetal heart rate, contractions, cervical dilation, and pain level. However, assessing DTRs is not a routine part of labor and delivery assessment unless there are signs of preeclampsia or eclampsia.
Choice D reason: Within the first trimester of pregnancy, it is important for the nurse to assess for signs of pregnancy-related nausea and vomiting, bleeding, infection, and ectopic pregnancy. However, assessing DTRs is not a routine part of first trimester assessment unless there are signs of neurological disorders or spinal cord injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: This is a correct answer because continuing to monitor the client for signs of an infection is important to detect any recurrence or complication of MRSA infection. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious skin, soft tissue, bone, joint, or bloodstream infections. The nurse should assess the client's vital signs, wound appearance, pain level, and laboratory results.
Choice B reason: This is not a correct answer because calling the healthcare provider for a prescription for linezolid is not necessary unless the client has an active MRSA infection that requires treatment. Linezolid is an antibiotic that can be used to treat MRSA infections, but it has potential side effects and interactions that need to be considered. The nurse should not prescribe or administer antibiotics without a valid order.
Choice C reason: This is a correct answer because collecting multiple sets of blood cultures for MRSA screening is important to identify any asymptomatic bacteremia or sepsis that could result from MRSA infection. MRSA can enter the bloodstream through wounds, catheters, or surgical sites and cause life-threatening complications such as endocarditis, osteomyelitis, or pneumonia. The nurse should obtain blood samples from different sites and times and send them to the laboratory for analysis.
Choice D reason: This is a correct answer because placing the client on contact transmission precautions is important to prevent the spread of MRSA to other clients, staff, or visitors. Contact transmission precautions include wearing gloves and gowns when entering the client's room, using dedicated or disposable equipment, and performing hand hygiene before and after contact with the client or their environment.
Choice E reason: This is not a correct answer because obtaining a sputum specimen for culture and sensitivity is not relevant to the client's history of MRSA wound infection. Sputum culture and sensitivity is a test that can be used to diagnose respiratory infections caused by bacteria, fungi, or viruses. The nurse should only obtain a sputum specimen if the client has signs or symptoms of a respiratory infection, such as cough, fever, chest pain, or dyspnea.
Correct Answer is ["A","C","D"]
Explanation
Choice A: Taking metformin with the morning and evening meal is a correct statement for the nurse to include, as this can improve the absorption and effectiveness of metformin and reduce the risk of gastrointestinal side effects. Therefore, this is a correct choice.
Choice B: Using sliding scale insulin for frequent blood glucose elevations is not a correct statement for the nurse to include, as this is not recommended for clients with type 2 DM who are taking metformin. This can cause hypoglycemia and complicate the management of blood glucose levels. This is an incorrect choice.
Choice C: Recognizing signs and symptoms of hypoglycemia is a correct statement for the nurse to include, as this can help the client identify and treat low blood glucose levels, which can occur with metformin use or other factors such as exercise, fasting, or alcohol intake. Therefore, this is another correct choice.
Choice D: Reporting persistent polyuria to the health care provider is a correct statement for the nurse to include, as this can indicate poor glycemic control or a complication of DM such as diabetic ketoacidosis or nephropathy. Therefore, this is another correct choice.
Choice E: Taking an additional dose for signs of hyperglycemia is not a correct statement for the nurse to include, as this can cause overdose or toxicity of metformin, which can lead to lactic acidosis and renal failure. This is another incorrect choice.
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