The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.

Answer and Explanation

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

Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.

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Correct Answer is ["A","E","F","G"]

Explanation

Urine protein: The presence of 3+ proteinuria is a significant finding suggestive of preeclampsia. Protein in the urine indicates renal involvement due to endothelial dysfunction, which is a hallmark complication in hypertensive disorders of pregnancy and needs immediate attention.
Respiratory rate: A respiratory rate of 16/min falls within the normal adult range of 12 to 20 breaths per minute. There is no evidence of respiratory distress, tachypnea, or bradypnea, so this finding does not suggest a prenatal complication.
Gravida/parity: Although the client has a history of one preterm birth, gravida and parity alone are not indicators of a current prenatal complication. It is important background information but does not point directly to an acute complication at this time.
Urine ketones: The absence of ketones in the urine is a normal finding. If ketones were present, it could suggest dehydration, starvation, or uncontrolled diabetes, but since they are negative, ketones are not a concern for prenatal complication here.
Headache: A severe headache unrelieved by acetaminophen in a pregnant woman can signal worsening hypertension or preeclampsia. Persistent headaches are a concerning symptom that warrants immediate evaluation and management to prevent maternal and fetal harm.
Fetal activity: Decreased fetal movement is a worrisome sign of possible fetal compromise, such as hypoxia or placental insufficiency. Reduced movements require further fetal assessment and monitoring to ensure fetal well-being.
Blood pressure: A blood pressure reading of 162/112 mm Hg is severely elevated and meets the diagnostic criteria for severe preeclampsia. Uncontrolled hypertension during pregnancy places both the mother and fetus at significant risk for serious complications.

A. Crackles in the lung bases B. Anorexia C. Bradycardia D. Polyuria during the day

Correct Answer is A

Explanation

A. Crackles in the lung bases: Left-sided heart failure leads to fluid buildup in the lungs due to the heart's inability to pump blood effectively. This fluid accumulation causes pulmonary congestion, which results in crackles, particularly in the lung bases. This is a common and expected finding in left-sided heart failure.

B. Anorexia: Anorexia may occur in heart failure, but it is not a primary or typical finding of left-sided heart failure. It is more commonly associated with right-sided heart failure, where digestive system congestion is more prevalent.

C. Bradycardia: Left-sided heart failure typically causes tachycardia (elevated heart rate) as the body compensates for the decreased cardiac output. Bradycardia is less commonly seen unless the client has an underlying arrhythmia or is on medications like beta-blockers.

D. Polyuria during the day: Polyuria, or excessive urination, is typically observed at night (nocturia) in clients with heart failure due to fluid redistribution when lying down. It is not commonly observed during the day.

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is pregnant The nurse is reviewing the client's medical record. Select 4 findings that the nurse should identify as a potential prenatal complication.

Correct Answer is ["A","E","F","G"]

Explanation

A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.