Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing laboratory results for a client who has HELLP syndrome.
Which of the following findings should the nurse expect? (Select all that apply.)
A. Hemoglobin of 9 g/dL
Hemoglobin of 9 g/dL indicates hemolysis, which is the breaking down of red blood cells. The normal range of hemoglobin for pregnant women is 11 to 16 g/dL.
B. Platelets of 90,000/mm3
Platelets of 90,000/mm3 indicate thrombocytopenia, which is a low platelet count. The normal range of platelets for pregnant women is 150,000 to 400,000/mm3.
C. AST of 120 U/L
AST of 120 U/L indicates elevated liver enzymes, which reflect liver injury. The normal range of AST for pregnant women is 10 to 40 U/L.
D. LDH of 600 U/L
LDH of 600 U/L indicates elevated lactate dehydrogenase, which is a marker of hemolysis. The normal range of LDH for pregnant women is 140 to 280 U/L.
E. WBC of 15,000/mm3
WBC of 15,000/mm3 indicates leukocytosis, which is not a feature of HELLP syndrome. The normal range of WBC for pregnant women is 5,000 to 15,000/mm3.
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Full Explanation
The correct answer is choice A, B, C and D. These choices reflect the laboratory findings that are expected in a client who has HELLP syndrome. HELLP syndrome is a rare pregnancy complication that is a type of preeclampsia and has similar symptoms. It can cause serious blood and liver problems.
Choice A is correct because hemoglobin of 9 g/dL indicates hemolysis, which is the breaking down of red blood cells. The normal range of hemoglobin for pregnant women is 11 to 16 g/dL.
Choice B is correct because platelets of 90,000/mm3 indicate thrombocytopenia, which is a low platelet count. The normal range of platelets for pregnant women is 150,000 to 400,000/mm3.
Choice C is correct because AST of 120 U/L indicates elevated liver enzymes, which reflect liver injury. The normal range of AST for pregnant women is 10 to 40 U/L.
Choice D is correct because LDH of 600 U/L indicates elevated lactate dehydrogenase, which is a marker of hemolysis. The normal range of LDH for pregnant women is 140 to 280 U/L.
Choice E is wrong because WBC of 15,000/mm3 indicates leukocytosis, which is not a feature of HELLP syndrome. The normal range of WBC for pregnant women is 5,000 to 15,000/mm3.
Similar Questions
A nurse is preparing to administer an IV loading dose of magnesium sulfate to a client who has preeclampsia with severe features.
Which of the following actions should the nurse take?
A. Administer the medication over 30 min using an infusion pump
Shorter infusion time may increase the risk of adverse effects.
B. Place the client in a supine position with a wedge under the right hip
The client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.
C. Monitor the client’s blood pressure every 15 min during the infusion
The client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.
D. Have calcium gluconate available at the bedside as an antidote.
Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia.However, it can also cause toxicity and respiratory depression if the serum level is too high.Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.
Full Explanation
The correct answer is choice D. Have calcium gluconate available at the bedside as an antidote. Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia. However, it can also cause toxicity and respiratory depression if the serum level is too high. Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.
Choice A is wrong because the medication should be administered over 20-30 minutes using an infusion pump.
A shorter infusion time may increase the risk of adverse effects.
Choice B is wrong because the client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.
Choice C is wrong because the client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.
Blood pressure is an indicator of the severity of preeclampsia and the effectiveness of magnesium sulfate therapy.
A nurse is caring for a client with gestational hypertension who is at risk for developing preeclampsia.
Which of the following interventions should the nurse implement to prevent this complication? (Select all that apply.).
A. Encourage bed rest in a dark and quiet environment
These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
B. Administer corticosteroids as prescribed
Corticosteroids are not used to prevent preeclampsia, but to enhance fetal lung maturity in case of preterm delivery.
C. Monitor fetal heart rate and movement
These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
D. Assess for headache, visual changes and epigastric pain
These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
E. Provide a diet high in protein and low in carbohydrates
A diet high in protein and low in carbohydrates is not recommended for gestational hypertension or preeclampsia. A balanced diet with adequate calcium, magnesium and antioxidants is advised.
Full Explanation
The correct answer is choice A, C and D. These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
Choice B is wrong because corticosteroids are not used to prevent preeclampsia, but to enhance fetal lung maturity in case of preterm delivery.
Choice E is wrong because a diet high in protein and low in carbohydrates is not recommended for gestational hypertension or preeclampsia. A balanced diet with adequate calcium, magnesium and antioxidants is advised.
A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with severe preeclampsia who is in labor.
Which of the following findings would indicate that the therapy is effective?
A. The client’s blood pressure is within normal range
The client’s blood pressure may not normalize even with magnesium sulfate therapy. Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure.Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.
B. The client’s urine output is at least 30 mL/hr
This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.
C. The client’s deep tendon reflexes are 2+
The client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant
D. The client’s respiratory rate is above 16 breaths/min
The client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.
Full Explanation
The correct answer is choice B. The client’s urine output is at least 30 mL/hr. This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.
A normal urine output is a sign that the kidneys are functioning well and that the fluid balance is maintained.
Choice A is wrong because the client’s blood pressure may not normalize even with magnesium sulfate therapy.
Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure. Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.
Choice C is wrong because the client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant.
A normal reflex response is 2+, but a lower response (1+ or 0) may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.
Choice D is wrong because the client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.
A normal respiratory rate is 12 to 20 breaths per minute, but a lower rate (less than 12) may indicate magnesium toxicity, which requires immediate treatment with calcium gluconate.