A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.
Which of the following actions should the nurse plan to take?

Ensure that the side rails are up on the client's bed.

Ambulate the client every 4 hr.

Check the fetal heart rate twice daily.

Provide the client with a low-protein diet.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should ensure that the side rails are up on the client's bed. This action is essential for the safety of the client with severe preeclampsia, as it prevents accidental falls or injuries. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and signs of organ damage, and it poses significant risks to both the mother and the fetus. By keeping the side rails up, the nurse can minimize the risk of falls and ensure the client's safety while in bed.

Choice B rationale:

Ambulating the client every 4 hours is not appropriate for a pregnant woman with severe preeclampsia. Preeclampsia can cause high blood pressure, swelling, and proteinuria. It is a serious condition that requires close monitoring and strict bed rest to prevent complications such as seizures or eclampsia. Ambulation may increase the risk of falls and is contraindicated in this situation.

Choice C rationale:

Checking the fetal heart rate twice daily is important in the care of a pregnant client with severe preeclampsia. However, ensuring the client's safety by keeping the side rails up on the bed takes priority. While monitoring the fetal heart rate is crucial for assessing the baby's well-being, it does not address the immediate safety concerns of the client, which can be addressed by maintaining the side rails up.

Choice D rationale:

Providing the client with a low-protein diet is not the correct action for a pregnant woman with severe preeclampsia. In fact, pregnant women with preeclampsia are often advised to increase their protein intake to help manage their condition. A low-protein diet can lead to malnutrition and may not provide the necessary nutrients for both the mother and the developing fetus. The primary focus should be on bed rest, monitoring vital signs, and managing symptoms to prevent complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.

Choice B rationale:

Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.

Choice C rationale:

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.

Choice D rationale:

Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.

A. Instruct the client about the importance of regular medical appointments. B. Encourage the client to participate in daily exercise. C. Explain proper foot care techniques to the client. D. Ensure that the client understands the medication regimen.

Correct Answer is D

Explanation

- A. Instructing the client about the importance of regular medical appointments is important but not the priority because it is a secondary prevention strategy that aims to detect and treat any complications or changes in the client's condition early. The client should have regular follow-up visits with an endocrinologist, a diabetes educator, an ophthalmologist, a podiatrist, a dentist, and other health care providers as needed.

- B. Encouraging the client to participate in daily exercise is important but not the priority because it is a tertiary prevention strategy that aims to reduce disability and improve quality of life for clients with chronic conditions. Exercise can help lower blood glucose levels, improve insulin sensitivity, reduce cardiovascular risk factors, enhance mood, and promote weight management for clients with type 1 diabetes mellitus. The client should consult with their health care provider before starting an exercise program and follow safety guidelines such as checking blood glucose levels before and after exercise, wearing appropriate footwear and clothing, carrying a source of fast-acting carbohydrate, and staying hydrated.

- C. Explaining proper foot care techniques to the client is important but not the priority because it is a tertiary prevention strategy that aims to prevent or minimize complications such as foot ulcers, infections, and amputations for clients with type 1 diabetes mellitus. Foot care includes inspecting feet daily for any injuries or abnormalities, washing feet with mild soap and warm water, drying feet thoroughly especially between toes, applying moisturizer to prevent dryness and cracking, trimming toenails straight across and filing edges smooth, wearing clean cotton socks and well-fitting shoes, avoiding walking barefoot or exposing feet to extreme temperatures or pressure, and seeking medical attention for any foot problems.

- D. Ensuring that the client understands the medication regimen is the nurse's priority because type 1 diabetes mellitus requires lifelong insulin therapy to maintain blood glucose levels within normal range and prevent complications such as ketoacidosis, hypoglycemia, and organ damage. The client needs to know how to administer insulin injections, monitor blood glucose levels, adjust insulin doses according to carbohydrate intake and physical activity, recognize and treat signs and symptoms of hypo- and hyperglycemia, and store insulin properly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

Correct Answer is C

Explanation

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

Correct Answer is D

Explanation

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease.Which of the following foods should the nurse recommend including in the preschooler's diet?

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area.Which of the following interventions should the nurse include?

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.
Which of the following actions should the nurse plan to take?