The nurse identifies assessment findings for an African-American ...

[WWatsford]

The nurse identifies assessment findings for an African-American client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+; 1+ edema hands, feet, ankles.
 
  On the next hourly assessment, which new assessment finding would indicate worsening of the condition?
  A) Blood pressure 158/100 mmHg
  B) Platelet count 150,000
  C) Urinary output 20 mL/hour
  D) Reflexes 2+

Question 2

A home care nurse is applying an Unna boot on a client with a stasis ulcer. Which statement will the nurse include when providing client education regarding this therapy?
 
  A) A nurse will change this dressing every 2 days.
  B) It is important that you maintain strict bed rest.
  C) The dressing will be applied to the entire length of your leg.
  D) The dressing I am applying is semi-rigid.

[abctaiwan]

Answer to Question 1

Answer: C

The decrease in urine output is an indication of decrease in glomerular filtration rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.

Answer to Question 2

Answer: D

The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the thigh but not the entire leg.

[WWatsford]

TYSM

[xiazhe]

Excellent