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A nurse is caring for a client.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

dark red vaginal bleeding, and abdominal pain

pain a 7 on a scale of 0 to 10

"My blood pressure has been high during the pregnancy."

Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

116/min, minimal variability noted

bilateral breath sounds clear

tearful

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

Rationale:

Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.

Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.

Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.

FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is []

Explanation

Potential condition: Systemic lupus erythematosus

Based on the provided information, the client is most likely experiencing Systemic Lupus Erythematosus (SLE). This is suggested by the presence of a macular rash on the cheeks, joint discomfort, fever, and elevated erythrocyte sedimentation rate (ESR).

Actions to Take

Anticipate administering prescribed immunosuppressant medication: This helps manage the autoimmune response and reduce inflammation.
Encourage client to avoid direct sunlight: Sun exposure can exacerbate lupus symptoms and trigger flares.

Parameters to Monitor

Vital signs every 4 hr: Monitoring vital signs helps track the client's overall condition and detect any changes that may indicate complications.
Erythrocyte sedimentation rate: Monitoring ESR helps assess the level of inflammation and the effectiveness of treatment.

A. Belching B. Sore throat C. Flatulence D. Abdominal pain

Correct Answer is D

Explanation

A. Belching: A common, benign post-procedure occurrence.

B. Sore throat: Expected due to endoscope insertion.

C. Flatulence: Typically benign and not concerning post-EGD.

D. Abdominal pain: May indicate a perforation or other serious complication and requires immediate evaluation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is assessing a client following an esophagogastroduodenoscopy. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago. Which in the client's findings are potential indication of increased intracranial pressure?

A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?

A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred?

A nurse is caring for a client. Exhibits Select the 2 actions that the nurse should take.

A nurse is consulting a pharmacological reference about medication compatibility prior to administering warfarin to a client. Which of the following medications should the nurse identify as being incompatible with warfarin?

A nurse is caring for a client in the emergency department. Exhibits Select the 4 interventions nurse should take.

A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?