A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

Administer diuretics.

Place on bedrest

Limit fluid intake.

Apply support stockings.

Answer and Explanation

The Correct Answer is D

Answer: D. Apply support stockings.

Rationale: Support stockings can help reduce ankle edema by promoting venous return and preventing fluid accumulation in the lower extremities. Diuretics, bedrest, and fluid restriction are not recommended for pregnant clients with ankle edema as they can cause dehydration, thromboembolism, and fetal compromise.

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Correct Answer is C

Explanation

The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.

A. Febrile B. Circulatory overload C. Acute hemolytic D. Anaphylactic

Correct Answer is D

Explanation

The correct answer is D. Anaphylactic reactions are characterized by urticaria, wheezing, hypotension, and bronchospasm. They are caused by an IgE-mediated hypersensitivity to plasma proteins in the donor blood.

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A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

Correct Answer is C

Explanation

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

Correct Answer is D

Explanation

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain. Which of the following conditions in the client's history should the nurse identify as a contraindication?

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

A nurse is monitoring a client's arterial pulses. The nurse should check for a dorsalis pedis pulse in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?