A client who is primigravida at term comes to the prenatal clinic and tells the practical nurse (PN) that she is having contractions every 5 minutes. The PN monitors the client for one hour using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. Which action should the PN take?

Tell the client to go directly to the hospital for admission to labor and delivery for active labor.

Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour.

Direct the client to check into the hospital within the next hour for evaluation of possible urinary tract infection.

Send the client home and tell her to drink at least 1,000 mL of fluid each day to flush her bladder.

Answer and Explanation

The Correct Answer is B

A. The client's contractions are not regular or intense enough to indicate active labor, so immediate hospital admission is not necessary.
B. Instructing the client to call the clinic when her contractions occur 5 minutes apart for one hour ensures she is monitored for the progression of labor and can seek timely assistance when labor becomes more active.
C. While a urinary tract infection could cause contractions, the primary focus should be on monitoring labor progression, not diagnosing a UTI at this stage.
D. Hydration is important, but the primary instruction should relate to monitoring contraction patterns for signs of active labor.

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Correct Answer is C

Explanation

A. Moisture is important for skin assessments but does not directly affect the accuracy of a temporal artery temperature measurement.
B. Elasticity is part of skin turgor assessments and does not impact the accuracy of the temperature reading from a temporal artery scanner.
C. Assessing skin color is crucial because variations in skin color can affect the accuracy of the temporal artery temperature measurement. For accurate results, the skin should be clean and free of color alterations.
D. Checking the temperature of the skin is the outcome of the measurement process rather than a preliminary assessment for a temporal artery scanner.

A. What are the voices uttering? B. When are the voices most disturbing? C. How does the client cope with the voices? D. Which medication works best?

Correct Answer is A

Explanation

A. Understanding what the voices are saying is the most important initial step in assessing auditory hallucinations. This information helps the PN gauge the content of the hallucinations, which is crucial for developing a treatment plan and determining the level of risk to the client or others.
B. While knowing when the voices are most disturbing provides useful information for managing symptoms, it is less critical than understanding the content of the hallucinations for developing an initial treatment plan.
C. Assessing how the client copes with the voices is important for ongoing management but comes after understanding what the voices are saying. Coping strategies can be developed based on the nature of the hallucinations.
D. Determining which medication works best is not an immediate priority during the initial assessment. Medication effectiveness will be evaluated over time rather than being a primary focus during the first report of hallucinations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) positions a temporal artery scanner as seen in the picture. Before obtaining a temperature measurement, which assessment of the skin should the PN complete?

Correct Answer is C

Explanation

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?

Correct Answer is A

Explanation

The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the PN monitor? Select all that apply.

An unlicensed assistive personnel (UAP) is assisting with the care of a client with a peripherally inserted central venous catheter (PICC). Which guidance should the practical nurse (PN) provide to the UAP?

The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location? (Select the correct location on the image)

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?

A client receives a prescription for digoxin 0.25 mg by mouth. The medication is available in 0.125 mg tablets. How many tablets should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Exhibits The practical nurse (PN) re-educates the client on methicillin-resistant Staphylococcus aureus (MRSA). Click to indicate whether the client's statement(s) indicate understanding or no understanding. Each row must have one option selected.

A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?

The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure?