The nurse identifies the following assessment findings on a client with preeclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet
On the next hourly assessment, which new assessment finding would be an indication of worsening of the preeclampsia? 1. Blood pressure 158/104
2. Urinary output 20 mL/hour
3. Reflexes 21
4. Platelet count 150,000
2
Rationale 1: The blood pressure has not had a significant rise.
Rationale 2: The decrease in urine output is an indication of decrease in GFR, which indicates a loss of renal perfusion. The most abnormal and life-threatening assessment finding is the urine output change.
Rationale 3: The reflexes are normal at 21.
Rationale 4: The platelet count is normal, although it is at the lower end.
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When a patient is monitored for aminoglycoside toxicity, what are the key aspects of assessment? You may select more than one answer
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Pre-operative care is given:
a. Before surgery b. After surgery c. In the recovery room d. During surgery
The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Which data is considered subjective?
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