Clinical Judgment Practice Exam Questions and Answer (All Correct) 100% 2022/2023

Clinical Judgment Practice Exam Questions and Answer (All Correct) 100% 2022/2023   Clinical Judgment Practice Exam When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)? A. Within the first trimester of pregnancy. B. If the client has an elevated blood pressure. C. When the client has ankle edema. D. During admission to labor and delivery. {{ANS- If the client has an elevated blood pressure. Rationale: A systolic greater than 140 mm Hg or a diastolic greater than 90 mm Hg is a sign of preeclampsia. Deep tendon reflexes (DTRs) greater than 2+ are also a sign of preeclampsia as is proteinuria greater than or equal to 1+ on dipstick measurement. Preeclampsia usually occurs after the 20th week of pregnancy. When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A. She received butorphanol 2 mg IVP during labor. B. The second stage of labor lasted 10 minutes. C. She is a gravida 6, para 5. D. She is over 35 years of age. {{ANS- She is a gravida 6, para 5. Rationale: Repeated gravid experiences cause the uterus to lose muscle tone (uterine atony) which is the most common cause of excessive bleeding following childbirth. An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first? A. Call respiratory therapy. B. Begin manual ventilation immediately. C. Monitor oxygen saturation levels every 5 minutes. D. Silence the alarm and call the technician. {{ANS- Begin manual ventilation immediately. Rationale: Ventilators provide mechanical respirations. A constant alarm and low oxygen saturation indicates a malfunction or problem with the respirations being provided.