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Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

Initiate contact precautions.

Check urinary output.

Decrease lighting in the client's room.

Monitor blood pressure.

Prepare for amniocentesis.

Apply Internal fetal monitor.

Assess DTR.

Get bed rest.

Answer and Explanation

Correct Answer : B,C,D,G,H

A. Contact precautions are not indicated based on the assessment findings provided.

Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B.   The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.

C.   a deep tendon reflex (DTR) grade of 3+ indicates a brisker than average response, which could be normal or potentially indicative of neurological hyperactivity. In such cases, creating a calming environment, which may include dimmed lighting, could potentially help in reducing stimuli that might exacerbate neurological excitability.
D.   The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E.   Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F.   Preeclampsia can have adverse effects on fetal well-being, including intrauterine growth restriction and placental insufficiency. However, an external fetal monitoring provides a more accurate assessment of fetal heart rate patterns and allows for closer monitoring of fetal status in cases of maternal hypertension.
G.   Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H.   Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A: Percussion should be performed with a cupped hand to provide effective airway clearance, not with a flat hand.
B: Postural drainage is typically performed multiple times per day to help clear secretions from the lungs in cystic fibrosis.
C: Postural drainage is often performed before meals to minimize the risk of vomiting due to manipulation of the abdomen.
D: Bronchodilators are not typically administered after postural drainage; they are used to help open the airways before the procedure.

Correct Answer is ["2"]

Explanation

To convert the prescribed dose of levothyroxine from micrograms to milligrams, we need to remember that 1 milligram (mg) is equal to 1000 micrograms (mcg). Therefore, 50 micrograms is equal to 0.050 mg. The available medication is 0.025 mg per tablet. To find out how many tablets the nurse should administer, we divide the prescribed dose in milligrams by the strength of the available tablets: 0.050 mg divided by 0.025 mg/tablet equals 2.

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Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.