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The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C,D
Rationale: Sure, here is the step-by-step rationale for why options C and D (Platelet count) are correct:
1. Blood pressure: In preeclampsia, high blood pressure is a key characteristic. Elevated blood pressure is a common finding in patients with preeclampsia, making option C consistent with preeclampsia.
2. Platelet count: HELLP syndrome is a serious complication of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. Therefore, a low platelet count is a hallmark feature of HELLP syndrome, aligning with option D.
Summary:
- Hemoglobin (Option A): Hemoglobin levels are not specific to either preeclampsia or HELLP syndrome. Therefore, this option is not selected.
- Alanine aminotransferase (ALT) (Option B): Elevated ALT levels are more specific to HELLP syndrome due to liver involvement. However, ALT
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Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.
Which statement should the nurse make?
- A. Your desire to be an organ donor must be documented in writing
- B. You have the right to change your decision about organ donation at any time.
- C. Discussing your wishes with your family can help ensure they are honored.
- D. Organ donation does not delay funeral arrangements or affect body appearance.
- E. Medical care provided before death will not be affected by your organ donor status.
Correct Answer: E
Rationale: The correct answer is E because it addresses a common misconception. Organ donor status does not affect medical care provided before death. Choice A is incorrect as organ donor consent can also be verbal. Choice B is incorrect because changing one's decision about organ donation may not always be feasible in emergency situations. Choice C is incorrect as discussing wishes with family does not guarantee they will be honored legally. Choice D is incorrect as organ donation may have some impact on funeral arrangements and body appearance.
Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer Ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: B,C,F
Rationale: Administering pain relief, protecting the abrasion, and elevating the limb reduce swelling and promote comfort.
A nurse in emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation
- B. obtain a throat culture
- C. suction the child's oropharynx
- D. prepare a cool mist tent
Correct Answer: A
Rationale: The correct action is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the airway can become severely compromised due to swelling of the epiglottis. Intubation may be necessary to secure the airway and ensure adequate oxygenation. Prompt intervention is crucial to prevent respiratory distress and potential death. Obtaining a throat culture (B) may delay essential treatment. Suctioning the oropharynx (C) can stimulate the epiglottis and worsen the obstruction. A cool mist tent (D) does not address the immediate need for securing the airway.