A nurse is planning care for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following actions should the nurse anticipate taking?

Administer a calcium channel blocker.

Encourage foods that are low in proteins.

Monitor for glycosuria.

Monitor IV fluid therapy.

Answer and Explanation

The Correct Answer is D

A. Administer a calcium channel blocker. Calcium channel blockers are used primarily for hypertension, angina, and certain cardiac conditions. They are not standard treatment for hyperemesis gravidarum, which is managed with fluid replacement, antiemetics, and nutritional support to prevent dehydration and electrolyte imbalances.
B. Encourage foods that are low in proteins. Protein intake is essential for fetal growth and maternal health. Clients with hyperemesis gravidarum may tolerate small, frequent meals with bland, high-protein foods better than low-protein options. Avoiding protein is not a recommended intervention, as it does not reduce nausea and may contribute to nutritional deficiencies.
C. Monitor for glycosuria. While glycosuria can occur during pregnancy, it is more relevant in the assessment of gestational diabetes rather than hyperemesis gravidarum. The primary concern in hyperemesis gravidarum is dehydration and electrolyte imbalances rather than glycosuria.
D. Monitor IV fluid therapy. Clients with hyperemesis gravidarum often experience severe nausea and vomiting, leading to dehydration and electrolyte imbalances. IV fluid therapy is a critical intervention to restore hydration, correct electrolyte imbalances, and prevent complications such as ketonuria and hypotension.

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Correct Answer is B

Explanation

A. "Document the infiltration." While documentation is necessary, it is not the first action the nurse should take. Immediate intervention is required to prevent further complications from IV infiltration, such as tissue damage or fluid leakage into surrounding tissues.
B. "Stop the infusion." The first action the nurse should take is to stop the IV infusion to prevent further infiltration of fluid into the surrounding tissues. Continuing the infusion could worsen swelling, discomfort, and potential tissue injury.
C. "Elevate the arm." Elevating the affected extremity can help reduce swelling by promoting fluid reabsorption, but this should be done after stopping the infusion to prevent additional fluid from accumulating in the tissues.
D. "Apply a warm compress." A warm compress can help promote absorption of non-vesicant solutions, while a cold compress is preferred for certain medications to reduce swelling and pain. However, applying a compress should only be done after stopping the infusion and assessing the severity of infiltration.

A. "Can you tell me about the stresses in your life?" B. "Has anyone in your family ever died by suicide?" C. "Do you have someone to discuss your feelings with? D. "Do you have a plan for harming yourself?"

Correct Answer is D

Explanation

A. "Can you tell me about the stresses in your life?" Identifying stressors is important for understanding the client’s situation, but it does not directly assess the immediate risk of suicide, which takes priority.
B. "Has anyone in your family ever died by suicide?" A family history of suicide can be a risk factor, but assessing the client’s current intent and plan is more urgent for determining immediate safety.
C. "Do you have someone to discuss your feelings with?" A support system is important, but it does not address the immediate risk of self-harm. If the client has a plan, immediate intervention is needed regardless of their support system.
D. "Do you have a plan for harming yourself?" Asking about a specific plan is the priority because it helps determine the level of risk and urgency of intervention. A detailed plan suggests a higher risk of acting on suicidal thoughts, requiring immediate safety measures.

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A nurse is planning care for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following actions should the nurse anticipate taking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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