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The nurse is continuing to care for the client.

Exhibits

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

Perform a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Administer betamethasone.

Monitor intake and output hourly.

Give antihypertensive medication.

Provide a low-stimulation environment

Maintain bed rest.

Answer and Explanation

Correct Answer : B,C,E,F,G

A. Perform a vaginal examination every 12 hr. Routine vaginal examinations are not indicated at this stage of care, as there are no signs of labor or uterine contractions. Vaginal exams should only be performed if there are indications of preterm labor or changes in maternal symptoms.

B. Obtain a 24-hr urine specimen. Collecting a 24-hour urine specimen allows for accurate measurement of total protein excretion, which is critical for confirming the severity of preeclampsia. This diagnostic tool helps guide further management decisions.

C. Administer betamethasone. Betamethasone is given to promote fetal lung maturity in the event of a preterm delivery, which is a significant risk at 31 weeks of gestation in the presence of severe preeclampsia. It reduces neonatal morbidity and mortality.

D. Monitor intake and output hourly. While monitoring fluid status is essential, hourly monitoring is not typically required unless there are signs of worsening renal function, oliguria, or fluid imbalance. Regular but less frequent monitoring is sufficient for this client.

E. Give antihypertensive medication. The client's blood pressure readings of 162/112 mm Hg and 166/110 mm Hg require prompt antihypertensive treatment to reduce the risk of complications such as stroke, placental abruption, or eclampsia.

F. Provide a low-stimulation environment. A quiet, low-stimulation environment helps reduce the risk of seizures, which is a concern for clients with severe preeclampsia. This intervention supports neurological stability.

G. Maintain bed rest. Bed rest minimizes physical exertion, helping to lower blood pressure and improve placental perfusion, which is critical for fetal well-being in a client with severe preeclampsia.

Nursing Test Bank

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Correct Answer is []

Explanation

Potential Condition: Kawasaki Disease

Kawasaki disease is a systemic vasculitis that primarily affects children under the age of 5 but can occur in older children. It presents with prolonged fever (lasting more than 5 days), conjunctival injection (red eyes without exudate), mucosal inflammation (strawberry tongue, red lips), maculopapular rash, and extremity changes (edema and peeling skin on hands and feet). Elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), high WBC count, and thrombocytosis (elevated platelets) are consistent with Kawasaki disease. If untreated, it can lead to coronary artery aneurysms.

Actions to Take:

Plan to administer high dose of aspirin:

High-dose aspirin is given to reduce inflammation and prevent thrombosis in coronary arteries, as Kawasaki disease increases the risk of coronary artery aneurysms.

Assess for neurological changes:

Neurological changes, such as irritability, can indicate aseptic meningitis or other central nervous system involvement, which can occur in Kawasaki disease.

Parameters to Monitor:

Daily weights:

Monitoring daily weights is essential to assess for fluid retention or overload, as Kawasaki disease can cause myocarditis and cardiac dysfunction.

Reports of chest pain or pressure:

Monitoring for chest pain or pressure is crucial to detect early signs of myocardial ischemia or coronary artery involvement, which are potential complications of Kawasaki disease.

A. Promoting health care access B. Encouraging clients to seek further information from the provider C. Addressing client needs when providing resources D. Making decisions about health care on clients' behalf E. Honoring family requests to withhold medical information

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

Explanation

A. Promoting health care access is a core element of advocacy, ensuring clients receive appropriate care.

B. Encouraging clients to seek information from providers empowers them to make informed decisions.

C. Addressing client needs when providing resources ensures care is client-centered.

D. Making decisions on behalf of clients without their input is not advocacy and undermines their autonomy.

E. Honoring family requests to withhold information violates the client's right to know about their care unless legally justified.

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The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in- service? (Select all that apply.)

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

Explanation

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The nurse is continuing to care for the client.

Exhibits

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