If a woman in her last trimester of pregnancy has marked edema, she may have
a. heart failure.
b. dehydration.
c. preeclampsia.
d. sodium overload.
C
After 20 weeks of gestation, marked edema, hypertension, and proteinuria are symptoms of preeclampsia. In nonpregnant individuals, edema may be a sign of heart failure or sodium over-load. Dehydration does not cause edema.
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A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis should the nurse use to address this concern?
a. Risk b. Actual c. Health-promotion d. Medical diagnosis
The nurse is attempting to place a urinary catheter for an older adult female client. The nurse is unable to visualize the client's urinary meatus. Which alternate position for catheterization may be appropriate for this client?
A) Side-lying, lifting up the buttock. B) Supine, with the HOB elevated at 30 °. C) Supine, with the head of bed (HOB) elevated at 45 °. D) Supine, with the bed flat, legs bent and apart in stirrups.
A patient taking spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of:
1. Hyperkalemia. 2. Hypokalemia. 3. Hypercalcemia. 4. Hyopcalcemia.
Early signs of pressure ulcers include which of the following?
a. Black eschar b. Tingling in the area c. An open blister d. Cracked and peeling skin