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The nurse is continuing to assist with the care of the client.

The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

Administer betamethasone.

Monitor intake and output every hour.

Assist RN with performing a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Provide a low-stimulation environment.

Give antihypertensive medication.

Maintain bedrest.

Answer and Explanation

Correct Answer : A,B,D,E,F,G

Administer betamethasone: Betamethasone is administered to pregnant clients at risk of preterm delivery to promote fetal lung maturity. Given the client's gestational age of 31 weeks and signs of severe preeclampsia, administering corticosteroids is critical to prepare for potential early delivery.
Monitor intake and output every hour: Severe preeclampsia can impair renal function, leading to decreased urine output and worsening fluid retention. Hourly monitoring of intake and output helps detect early signs of renal compromise and fluid overload, both of which require immediate intervention.
Assist RN with performing a vaginal examination every 12 hr: Vaginal examinations are avoided in cases of severe preeclampsia unless absolutely necessary because they can stimulate uterine contractions or introduce infection. Therefore, routinely assisting every 12 hours with vaginal exams is not appropriate in this client's plan of care.
Obtain a 24-hr urine specimen: A 24-hour urine collection assesses the degree of proteinuria and provides a clearer diagnostic picture of the severity of preeclampsia. Quantifying protein excretion helps guide clinical management and decisions about timing of delivery.
Provide a low-stimulation environment: A calm, quiet environment minimizes the risk of seizure activity in clients with severe preeclampsia. Reducing auditory, visual, and environmental stimulation is a standard preventative measure to decrease neurological irritability.
Give antihypertensive medication: Severe hypertension must be promptly treated to prevent complications like stroke, placental abruption, and progression to eclampsia. Administering antihypertensive therapy helps stabilize maternal blood pressure and protects both maternal and fetal health.
Maintain bedrest: Bedrest helps reduce blood pressure and physical stress, promoting better perfusion to the placenta. Although strict bedrest is controversial long-term, short-term bedrest is often used in severe preeclampsia management while stabilization measures are implemented.

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

Explanation

request a prescription for an increase in statin medication: Although the client's total cholesterol is elevated at 230 mg/dL, adjusting lipid management is not the immediate priority during an acute chest pain episode. The immediate focus should be stabilizing airway, breathing, and circulation.
prepare the client for cardiac catheterization: Cardiac catheterization may ultimately be needed to assess coronary artery blockages, but before this, the client must be stabilized with oxygen and medications to control chest pain and improve oxygenation.
administer oxygen at 2 L/min via nasal cannula: The client’s oxygen saturation dropped to 92% on room air, which is low for someone experiencing chest pain and possible myocardial ischemia. Administering supplemental oxygen improves myocardial oxygen supply and reduces cardiac workload, addressing airway and breathing priorities.
check a STAT cardiac troponin: The client’s initial troponin level was normal, but troponin can take several hours to rise after myocardial injury. While monitoring serial troponins is important, managing oxygenation and chest pain relief takes precedence right now.
administer sublingual nitroglycerin: After ensuring oxygenation, sublingual nitroglycerin should be administered to relieve chest pain by dilating coronary arteries and decreasing myocardial oxygen demand. It helps reduce ischemia and may prevent further cardiac injury.
request a prescription for a beta-blocker: Beta-blockers help control heart rate and blood pressure but are not the immediate first-line response for active chest pain and oxygen desaturation. Oxygen and nitroglycerin must be prioritized first to address the acute ischemic event.

A. Place the client in a supine position B. Empty the collection chamber every 8 hr C. Ensure the device is kept below the level of the client's chest. D. Clamp the chest tube every 4hr

Correct Answer is C

Explanation

A. Place the client in a supine position: A supine position can impair lung expansion and increase the risk of respiratory complications. Clients with a chest tube are best positioned in a semi-Fowler’s or high-Fowler’s position to promote lung re-expansion and ease of breathing.

B. Empty the collection chamber every 8 hr: The collection chamber in a chest drainage system should not be emptied routinely, it should be emptied as needed to prevent it from overfilling. It is a closed system, and breaking it by emptying can introduce infection or disrupt the pressure needed for effective drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the chest drainage system below chest level uses gravity to promote drainage and prevents backflow of fluid or air into the pleural space. This positioning is essential to maintain the effectiveness and safety of the chest tube system.

D. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended as it can lead to a dangerous buildup of air (tension pneumothorax). Clamping is reserved for specific, short-term procedures under direct provider orders, such as changing the drainage system.

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The nurse is continuing to assist with the care of the client. The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Complete the following sentence by using the lists of options. After notifying the provider, the nurse should first ______ and then _______

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

Explanation

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

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The nurse is continuing to assist with the care of the client.

The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.