Nokea
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
- A. 136/88 to 144/93
- B. 132/78 to 124/76
- C. 114/70 to 140/88
- D. 140/90 to 148/98
Correct Answer: C
Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.
You may also like to solve these questions
The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?
- A. A client recovering from a stroke with an oxygen saturation rate of 99%
- B. A client three days post-coronary artery bypass graft with an oral temperature of 100.2°F
- C. A client admitted one hour ago with rales and shortness of breath
- D. A client being prepared for discharge following a right colectomy
Correct Answer: C
Rationale: The client admitted one hour ago with rales and shortness of breath indicates potential acute respiratory distress, possibly from pulmonary edema or pneumonia, requiring immediate assessment. The other clients are stable or less urgent.
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
- A. Position on side or abdomen.
- B. Maintain elbow restraints in place unless she is being directly supervised.
- C. Clean suture line every shift.
- D. Offer pacifier when she cries.
Correct Answer: B
Rationale: Placing the infant on her abdomen may allow for injury to the suture line. Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. The suture line is cleaned as often as every hour to prevent crusting and scarring. Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.
The physician orders Zestril (lisinopril) and Lasix (furosemide) to be administered at the same time to a client with hypertension. The nurse should:
- A. Question the order
- B. Administer the medications as ordered
- C. Administer the medications separately
- D. Contact the pharmacy
Correct Answer: B
Rationale: Lisinopril (an ACE inhibitor) and furosemide (a diuretic) are commonly prescribed together for hypertension to reduce blood pressure synergistically. Administering them as ordered is appropriate as there is no contraindication to concurrent use.
The nurse is caring for a client with a history of cirrhosis. The nurse should give priority to:
- A. Monitoring for bleeding
- B. Administering diuretics
- C. Monitoring blood glucose
- D. Assessing for infection
Correct Answer: A
Rationale: Cirrhosis impairs clotting factor production, increasing bleeding risk, so monitoring for bleeding is a priority.
The client with a history of diabetes insipidus is admitted with polyuria,polydipsia,and mental confusion. The priority intervention for this client is:
- A. Measuring the urinary output
- B. Checking the vital signs
- C. Encouraging increased fluid intake
- D. Weighing the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalances. Checking vital signs is the priority to assess for instability (e.g. hypotension tachycardia) and guide immediate treatment. The other interventions are secondary.