Nursing a Concept Based Approach to Learning Test Bank Free

Questions 14

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Nursing a Concept Based Approach to Learning Test Bank Free Questions

Question 1 of 5

Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia?

Correct Answer: B

Rationale: When caring for a laboring client diagnosed with preeclampsia, it is important to be mindful of certain considerations to ensure the safety and well-being of both the mother and the baby. Placing the client in left lateral position when she feels the urge to push is crucial in cases of preeclampsia as it helps to optimize maternal and fetal oxygenation. This position can help improve blood flow to the placenta and reduce the risk of decreased perfusion due to the elevated blood pressure associated with preeclampsia. By maintaining the client in the left lateral position during pushing, it can help prevent potential complications and support better outcomes for both the mother and baby.

Question 2 of 5

The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply.

Correct Answer: B

Rationale: Atrial septal defect (ASD) is a congenital heart defect where there is an abnormal opening between the atria of the heart. The manifestations of ASD can vary depending on the size of the defect and the individual. However, common manifestations may include:

Question 3 of 5

The nurse is evaluating teaching provided to a client with peripheral vascular disease (PVD). Which client observation indicates teaching has been effective?

Correct Answer: B

Rationale: Option B, washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer, indicates effective teaching for a client with peripheral vascular disease (PVD). Proper hygiene, including gentle washing with mild soap, thorough drying to prevent moisture-related skin breakdown, and moisturizing to prevent dry skin and promote circulation, are key components of self-care for individuals with PVD. Option A is incorrect because sitting with a pillow behind the knees does not specifically address PVD self-care. Option C is incorrect because crossing the left leg over the right while sitting does not relate to appropriate PVD management. Option D is incorrect because smoking in any form is detrimental to vascular health and should be discouraged in PVD management.

Question 4 of 5

A patient comes into the emergency department with manifestations of appendicitis. What is the highest priority when caring for this patient?

Correct Answer: C

Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.

Question 5 of 5

An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?

Correct Answer: B

Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.

Similar Questions

An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?
A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family?
Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia?
The nurse is preparing teaching for a patient with mild osteoarthritis of the knees. Which medication treatments should the nurse include in these instructions? Select all that apply.
A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client?

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