The nurse is continuing to care for the client.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° F). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Day 1, 0930:. Oxygen saturation 97% on room air.
Temperature (oral) 37.1° C (98.8° F). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 99% on room air.
Drag words from the choices below to fill in each blank in the following.
sentence.
The client is at greatest risk for developing Target 1 and Target 2. Conditions.

Placental abruption.

Cervical insufficiency.

Seizures.

Hypoglycemia.

Heart failure.

Answer and Explanation

Correct Answer : A,C

The correct answers are Choices A and C.

Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.

Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.

Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.

Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.

Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.

Nursing Test Bank

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Correct Answer is D,C,B,A

Explanation

In the event of a fire, the nurse should prioritize safety and follow the facility’s emergency protocols, which typically align with the “RACE” acronym: Rescue: d. Transport the client to another area of the nursing unit. Ensure the client is safe from immediate danger. Alarm: c. Activate the facility’s fire alarm system. Alert others in the facility by activating the fire alarm. Confine: b. Close all nearby windows and doors. Prevent the spread of fire by closing doors and windows. Extinguish: a. Use the unit’s fire extinguisher to attempt to put out the fire. If it’s safe to do so, attempt to extinguish the fire using a fire extinguisher. Remember, the safety of the client and the nurse is the top priority. If the fire is too large or the situation too dangerous, the nurse should evacuate and wait for the fire department to handle the situation. Always follow the specific procedures of your healthcare facility.

A. "You can add the medication to a half-cup of your child's favorite juice." B. "Limit your child's potassium intake while she is taking this medication." C. "Have your child drink a small glass of water after swallowing the medication." D. "Repeat the dose if your child vomits within 1 hour after taking the medication." .

Correct Answer is C

Explanation

The correct answer is choiceC. “Have your child drink a small glass of water after swallowing the medication.”

Choice A rationale:

Adding digoxin to a half-cup of juice is not recommended because it can affect the absorption of the medication.It is best to give digoxin on an empty stomach or with a small amount of food if necessary.

Choice B rationale:

Limiting potassium intake is incorrect.In fact, maintaining adequate potassium levels is important because low potassium levels can increase the risk of digoxin toxicity.

Choice C rationale:

Having the child drink a small glass of water after taking the medication helps ensure that the medication is swallowed completely and reduces the risk of esophageal irritation.

Choice D rationale:

Repeating the dose if the child vomits within 1 hour is not recommended. If a dose is vomited, it should not be repeated to avoid the risk of overdose.The next dose should be given at the regular scheduled time.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is D,C,B,A

Explanation

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is near the end of life and is on complete bed rest.The client states that he needs to have a bowel movement and the nurse offers a bedpan.The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?

A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh.Which of the following actions should the nurse take?

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk.After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test?

A nurse is planning to conduct a support group for adolescents who have cancer.Which of the following actions should the nurse include during the orientation phase?