a nurse is caring for a client who has severe preeclampsia which of the following interventions should the nurse include in the plan of care
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

1. A nurse is caring for a client who has severe preeclampsia. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct intervention for a client with severe preeclampsia is to monitor intake and output. This is crucial to assess kidney function, fluid balance, and detect any signs of deterioration. Administering magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia, but it is not the primary intervention related to care planning. Placing the client in the left lateral position is not a specific intervention for managing preeclampsia. Providing a low-sodium diet is not typically recommended for clients with severe preeclampsia as sodium restriction is not a primary treatment modality for this condition.

2. A healthcare provider is reviewing laboratory results for a client who has diabetes mellitus. Which of the following tests is an indicator of long-term blood glucose control?

Correct answer: B

Rationale: The correct answer is B, Glycosylated hemoglobin (HbA1c). HbA1c provides a measure of long-term blood glucose control over the past 2-3 months. This test reflects the average blood glucose levels during this period, making it a valuable tool in managing diabetes. Choices A, C, and D are not indicators of long-term blood glucose control. Fasting blood glucose measures the current glucose level after a period of not eating, random blood glucose provides a snapshot of the current glucose level, and postprandial blood glucose measures the glucose level after a meal.

3. Which electrolyte imbalance is most common in patients receiving furosemide?

Correct answer: A

Rationale: The correct answer is A, Hypokalemia. Furosemide, a loop diuretic, commonly leads to potassium loss in the urine, causing hypokalemia. This electrolyte imbalance should be closely monitored in patients taking furosemide. Choices B, C, and D are incorrect because hypercalcemia, hyponatremia, and hyperkalemia are not typically associated with furosemide use.

4. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Correct answer: D

Rationale: The correct answer is D because viewing the newborn's actions as uncooperative may indicate the client is struggling to bond, requiring intervention. Choices A, B, and C do not raise concerns about the bonding process between the client and the newborn. Holding the newborn in an en face position is a positive interaction. Asking the father to change the newborn's diaper involves family participation in care. Requesting the nurse to take the newborn to the nursery so she can rest is a valid request for maternal self-care.

5. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

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