coma. Cardiac effects include slowed con-While the nurse should identify which med-duction and cardiac arrest. Choicesa,b, andications the client is taking, it is moredare incorrect. These conditions are notimportant to know the onset time of theconsidered side effects related to the admin-stroke to determine the course of action foristration of IV lidocaine.administering t-PA. Choicebis incorrect. ACategory:Physiological Integrity: Pharma-complete health assessment and history iscological and Parenteral Therapiesnot possible when a client is receiving emer-Subcategory:Adult: Cardiovasculargency care. Choicedis incorrect. Upcoming128.c.DisordersThe client is most likely experiencingsurgical procedures may need to be delayed,because the administration of t-PA is theHELLP syndrome (hemolysis, elevated liverpriority.enzymes, lower platelet count), which canCategory:Physiological Integrity: Reduc-be a complication of preeclampsia ortion of Risk Potentialeclampsia. In patients experiencing HELLPsyndrome, a coagulation cascade is acti-Subcategory:Adult: Neurological Disorders130.d.Nuts are a good source of thiamine. Choicesvated. This in turn creates fbrin formationaandcare incorrect. Apples and greenin small blood vessels, leading to microangi-beans are good sources of vitamins A and Copathic hemolytic anemia and destructionbut not thiamine. Choicebis incorrect.of red blood cells with consumption ofFish is a good source of protein but notplatelets. Palpation of the abdomen is con-thiamine.traindicated at this time due to the potentialCategory:Health Promotion and Mainte-for liver rupture. Choiceais incorrect.nanceAdministration of magnesium sulfate perSubcategory:Mental Health: Substanceorder should be continued to assist in theAbusemanagement of the client’s eclampsia.Choicebis incorrect. Fetal monitoringshould occur to assess fetal well-being.Choicedis incorrect. The client is mostlikely experiencing HELLP syndrome andshould be prepared for delivery.Category:Safe and Effective Care Environ-ment: Management of CareSubcategory:Maternal Infant: MaternalComplications: Antepartum157
––NCLEX-RN PRACTICE TEST 2131.b.A client with a laryngectomy cannot speak,but still needs to communicate. The nurseshould plan to develop an alternative com-munication method. Choiceais incorrect.To prevent injury to the tracheal mucosa,the nurse should defate the tracheostomycuff or use the minimal leak technique.Choicecis incorrect. Post-laryngectomy,edema interferes with the ability to swallowand necessitates tube (enteral) feedings.Choicedis incorrect. To decrease edema,the nurse should place the client in thesemi-Fowler’s position.Category:Psychosocial IntegritySubcategory:Adult: Respiratory Disorders132.c.This response acknowledges the father’sconcerns and encourages the father to elab-orate on his feelings. Choiceais incorrect.
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