A nurse in an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?

A client who is at 34 weeks of getation and reports double vision

A client who is at 38 weeks of gestation and reports leg cramps

A client who is at 8 weeks of gestation and reports excessive salivation

A client who is at 24 weeks of gestation and reports periodic finger numbness

Answer and Explanation

The Correct Answer is A

A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.

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Correct Answer is B

Explanation

A. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, not for those with bacterial meningitis.
B. Droplet. This is correct because bacterial meningitis is transmitted through respiratory secretions. Droplet precautions, including wearing a mask when within 3 to 6 feet of the client, are necessary to prevent the spread of infection.
C. Contact. This is incorrect because bacterial meningitis is not primarily transmitted through direct contact with surfaces or bodily fluids, making contact precautions unnecessary.
D. Airborne. This is incorrect because bacterial meningitis does not spread through airborne particles that remain suspended in the air, so airborne precautions are not required.

A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. B. Check the patency of the tubing every 2 hr. C. Keep the drainage system above the level of the client's chest. D. Empty the collection chamber every 8 hr.

Correct Answer is A

Explanation

A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.

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A nurse in an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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