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 B

Explanation

A. Documenting the client's loss of memory is important for ongoing assessment, but it is not the immediate action to take when the client is confused about the day of the week.
B. Reminding the client of the day of the week is a direct intervention to help orient the client, which is a primary approach for managing acute confusion or disorientation.
C. Notifying the family of the change in the client’s condition may be necessary if confusion persists or worsens, but initial steps should focus on immediate management of the confusion.
D. Encouraging the client to rest is a general supportive action but does not address the specific issue of confusion about the day of the week.

A. "MRSA is not that big of a deal." B. "I should wash my hands and encourage others who are around me to wash their hands." C. "I will no longer be able to transmit MRSA once my surgical site is completely healed." D. "My diet makes a difference in my ability to heal." E. "I should only take antibiotics until I feel better."

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

"MRSA is not that big of a deal."
No Understanding: MRSA is a serious infection that can be difficult to treat and can spread. It is important for the client to understand the severity of MRSA.
"I should wash my hands and encourage others who are around me to wash their hands."
Understanding: Hand hygiene is critical in preventing the spread of MRSA. The client is aware of the importance of hand washing for infection control.
"I will no longer be able to transmit MRSA once my surgical site is completely healed."
No Understanding: MRSA can be a persistent infection, and healing of the surgical site does not guarantee that MRSA cannot be transmitted. Proper infection control measures must continue.
"My diet makes a difference in my ability to heal."
Understanding: Nutrition plays a role in the healing process and overall recovery. A balanced diet supports the immune system and aids in wound healing.
"I should only take antibiotics until I feel better."
No Understanding: It is crucial to complete the full course of antibiotics as prescribed to ensure the infection is fully treated and to prevent resistance

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Naxlex Comprehensive Predictor Exams

An older adult client who was admitted to a long-term care facility yesterday is confused about what day of the week it is. The history does not indicate that the client was confused prior to admission. Which action should the practical nurse (PN) take?

Correct Answer is B

Explanation

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.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

The practical nurse (PN) is turning a dependent bedridden client without assistance. Which action will best ensure the client's safety?

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?

The practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?

An older adult client returns to the clinic for a follow-up visit with the healthcare provider for management of depression related to the death of a child, who was killed 6 months ago by a drunk driver. Which finding indicates to the practical nurse (PN) that the client is improving?