Try Naxlex NCLEX-RN (Free-Trial)

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.

Provide a low-stimulation environment.

Maintain bed rest

Give antihypertensive medication

Obtain a 24-hr urine specimen

Perform a vaginal examination every 12 hr.

Monitor intake and output hourly

Administer betamethasone

Answer and Explanation

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

Rationale:

A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.

B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.

C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.

D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.

E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.

F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.

G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. Use a loud tone of voice when speaking with the client: Clients with visual impairments do not necessarily have hearing loss. Speaking loudly is unnecessary and may be perceived as disrespectful or startling. Clear, calm, and descriptive communication is more appropriate.

B. Rearrange client’s bedside table items frequently: Frequently moving personal items creates confusion and increases the risk of accidents or frustration for a visually impaired client. Consistent item placement enhances safety and independence.

C. Guide the client by walking parallel with them: Walking parallel without physical or verbal guidance may not be helpful. It’s more effective to offer the client your arm so they can follow your movement and safely navigate their surroundings.

D. Remove objects from client's path to the bathroom: Clearing obstacles from the client's walking path reduces the risk of tripping and falls. This is a key safety intervention for clients with reduced visual sensory perception and promotes independent, safe mobility.

A. Hypotension B. Hypovolemia C. Cardiogenic shock D. Left ventricular failure

Correct Answer is D

Explanation

Rationale:

A. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.

B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.

C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.

D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

Correct Answer is D

Explanation

A nurse is caring for a client who had a laparoscopic cholecystectomy and is experiencing abdominal distention. Which of the following actions should the nurse take?

A nurse on an inpatient mental health unit is caring for a client.Exhibits Select 4 findings the nurse should identify as positive manifestations of the clients diagnosis

The nurse continues to care for the client.Exhibits The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.

A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto?

A nurse is caring for a client who has AIDS. The client states, "My mouth is sore when I eat." Which of the following instructions should the nurse provide?

A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

A nurse is reviewing the BUN result of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory studies should the nurse recognize as another renal function study that should be monitored?

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.