Exhibits

The client is at risk of developing
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and
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","C","F"]

Explanation

A. Current level of consciousness. Changes in mental status, such as confusion or decreased alertness, can indicate hypoxia, infection, or worsening respiratory distress. Given the client’s history and symptoms, altered consciousness requires immediate follow-up to assess for possible hypoxemia or sepsis.
B. Heart rate. While the heart rate of 104/min is slightly elevated, it is not critically abnormal. Tachycardia can occur due to fever, anxiety, or respiratory distress, but it is not the most urgent concern compared to other findings.
C. Respiratory rate. The client’s respiratory rate of 30/min is significantly elevated, indicating possible respiratory distress. Increased work of breathing suggests inadequate oxygenation or potential pneumonia, requiring immediate evaluation and intervention.
D. Chronic health condition. The client has Parkinson’s disease and a history of smoking, both of which are important considerations in their overall care but do not require immediate intervention in the current scenario.
E. Tremors. Tremors are a common symptom of Parkinson’s disease and do not indicate an acute emergency. They do not require urgent follow-up in this case.
F. Oxygen saturation level. An oxygen saturation of 89% on room air is concerning, as it indicates hypoxemia. Immediate intervention, such as supplemental oxygen and further respiratory assessment, is necessary to prevent further deterioration.

A. Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above. B. Start an IV bolus of lactated Ringer's solution. C. Document the blood product transfusion in the client's medical record. D. Discard the blood bag in the client's trash can after the transfusion. E. Assist with obtaining the first unit of packed RBCs from the blood bank F. Monitor the client for the first 15 min of the transfusion.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.

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Exhibits The client is at risk of developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Exhibits Select the 3 findings that require immediate follow-up.

Correct Answer is ["A","C","F"]

Explanation

The nurse is reviewing the client's medical record. Exhibits For each potential nursing action, click to specify if the action is indicated or not indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require dropdownas evidenced by the client'sdropdown

A nurse is caring for a client who is at 26 weeks of gestation. Which of the following statements indicates the client is having difficulty accepting the body image changes associated with pregnancy?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

A nurse is caring for a client who is experiencing delirium. Which of the following findings should the nurse expect?

A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for this client?

A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information?

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

Exhibits

The client is at risk of developing
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and
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