The nurse is continuing to care for the client.

Exhibits
Which of the following conditions is the client is at greatest risk for developing? Select all that apply

seizures

hypoglycemia

cervical insufficiency

heart failure

placental abruption

Answer and Explanation

Correct Answer : A,E

Rationale for Correct Choices

• Seizures: The client’s BP of 166/110 mm Hg, +3 pitting edema, hyperreflexia (4+), and 3+ proteinuria are hallmark findings of severe preeclampsia, which places the client at high risk for progression to eclampsia (seizures). Cerebral edema and vasospasm associated with preeclampsia can precipitate convulsions if untreated.

• Placental abruption: Severe hypertension causes vasoconstriction and endothelial damage in uteroplacental vessels, predisposing the placenta to premature separation. This can lead to fetal distress, decreased movement, and potential maternal hemorrhage, both consistent with placental abruption risk in preeclampsia.

Rationale for Incorrect Choices

• Hypoglycemia: This condition is not related to preeclampsia; it more commonly occurs in clients with diabetes or from medication effects such as insulin overuse.

• Cervical insufficiency: This condition involves painless cervical dilation leading to preterm birth, unrelated to hypertension or proteinuria.

• Heart failure: Although hypertension increases cardiac workload, the current findings (normal heart rate, no dyspnea, clear lungs) do not indicate heart failure in this client.

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Correct Answer is A

Explanation

Rationale:
A. A client who is receiving a blood transfusion and reports low-back pain: Low-back pain during a blood transfusion indicates a possible acute hemolytic reaction caused by ABO incompatibility. This is a life-threatening emergency that requires immediate discontinuation of the transfusion and notifying the provider to prevent renal failure and shock.

B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x10⁶/µL (4.2–5.4 x10⁶/µL): Although the RBC count is slightly low, this finding is not immediately life-threatening. The provider should be informed, but the client does not require urgent intervention.

C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing: Small clots are expected during the first 24 to 36 hours post-TURP due to residual bleeding from the surgical site.

D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag: Small amounts of bloody mucus are normal during the early postoperative phase as the bowel mucosa heals.

A. The nurse positions a client who is postoperative in a semi-Fowler's position. B. The nurse uses clean gloves when administering an enema. C. The nurse performs auscultation of the lungs without lifting the gown. D. The nurse applies a cold compress to reduce localized swelling.

Correct Answer is C

Explanation

Rationale:
A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler’s promotes lung expansion and comfort postoperatively, especially after abdominal or thoracic surgery, making this an appropriate nursing action.

B. The nurse uses clean gloves when administering an enema: Clean gloves are sufficient for enema administration since it is a clean (not sterile) procedure, and this reflects correct practice.

C. The nurse performs auscultation of the lungs without lifting the gown: Clothing or gowns interfere with accurate transmission of breath sounds, leading to possible misinterpretation. The gown should be lifted or moved aside to properly auscultate.

D. The nurse applies a cold compress to reduce localized swelling: Cold therapy decreases blood flow and inflammation, making this an appropriate intervention for localized swelling or injury.

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The nurse is continuing to care for the client. Exhibits Which of the following conditions is the client is at greatest risk for developing? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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The nurse is continuing to care for the client.

Exhibits
Which of the following conditions is the client is at greatest risk for developing? Select all that apply