A nurse is planning care for a client who was recently admitted to the medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential condition:

The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.

The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.

Action to take:

In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.

Parameters to monitor:

To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Ketorolac is an NSAID that carries a risk of gastrointestinal bleeding and is contraindicated in clients with cholelithiasis due to its potential to cause biliary colic.
B. Omeprazole is a proton pump inhibitor used to reduce gastric acid secretion and prevent ulcers but does not provide immediate pain relief.
C. Metoclopramide is a prokinetic agent that helps with gastric emptying and may be used to relieve symptoms such as nausea and vomiting but is not indicated for pain relief.

D. Acetaminophen is a suitable PRN pain medication for a client experiencing moderate abdominal pain due to cholelithiasis. It provides effective analgesia without exacerbating symptoms or causing adverse effects on the gastrointestinal system, which is crucial for clients with gallstone-related pain.

A. Position the client in reverse Trendelenburg. B. Assist the client into the lithotomy position. C. Insert a pillow under the client's knees. D. Place a wedge under one of the client's hips.

Correct Answer is D

Explanation

A. Positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration.
B. The lithotomy position is not appropriate for cesarean birth and may compromise blood flow to the placenta.
C. This position could increase pressure on the vena cava and compromise placental blood flow.
D. This lateral tilt relieves pressure on the inferior vena cava, preventing decreased placental blood flow.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer?

Correct Answer is D

Explanation

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?

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