The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on 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 159/100 mmHg
B)Urinary output 40 mL/hour
C)Urine protein 2+
D)Lungs clear to auscultation

Question

Quizplus · Accepted Answer

A)The assessment finding most abnormal is the increase in urine protein. This indicates worsening of the condition. Urinary output is still greater than 30 mL/hour, so this is not concerning yet. The blood pressure increase is not significant. Lungs clear to auscultation is an improvement in her condition.
B)The assessment finding most abnormal is the increase in urine protein. This indicates worsening of the condition. Urinary output is still greater than 30 mL/hour, so this is not concerning yet. The blood pressure increase is not significant. Lungs clear to auscultation is an improvement in her condition.
C)The assessment finding most abnormal is the increase in urine protein. This indicates worsening of the condition. Urinary output is still greater than 30 mL/hour, so this is not concerning yet. The blood pressure increase is not significant. Lungs clear to auscultation is an improvement in her condition.
D)The assessment finding most abnormal is the increase in urine protein. This indicates worsening of the condition. Urinary output is still greater than 30 mL/hour, so this is not concerning yet. The blood pressure increase is not significant. Lungs clear to auscultation is an improvement in her condition.

The Nurse Identifies Assessment Findings for a Client with Preeclampsia