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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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Free Nursing Study Resources

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

Explanation

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

A. Vitamin D, B. Ranitidine C. Naproxen D. Docusate sodium

Correct Answer is C

Explanation

A. Vitamin D: Vitamin D is a supplement used to support bone health and calcium regulation. It does not have a known adverse interaction with clopidogrel and does not increase the risk of bleeding when taken concurrently.

B. Ranitidine: Ranitidine is an H2 receptor antagonist used to reduce stomach acid. It has minimal interaction with clopidogrel and does not significantly impact bleeding risk, making it generally safe to use alongside antiplatelet therapy.

C. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding when used with clopidogrel, an antiplatelet agent. Combining these medications heightens the risk of serious bleeding complications and should be avoided without provider guidance.

D. Docusate sodium: Docusate sodium is a stool softener that facilitates easier bowel movements. It does not have a significant interaction with clopidogrel and does not affect bleeding risk, making it generally safe for clients requiring antiplatelet therapy.

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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

The nurse has reviewed the Vital Signs at 1000. For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

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

Explanation

A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel?

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.