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A nurse in an antepartum unit is caring for a client.

Exhibits

Click to highlight the findings that indicate the interventions have been effective. To deselect a finding, click on the finding again.

Nurses' Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

Client rates pain with contractions as a 3 on a scale of 0 to 10

FHR 150/min with moderate variability. Accelerations present, no decelerations noted

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Feeling pulsations in the neck is not an expected sensation during electroconvulsive therapy (ECT). The client is under general anesthesia and does not feel the procedure.
B. The client typically wakes up within 5 to 10 minutes after ECT, though they may remain drowsy for a while. 30 minutes is too long for initial awakening.
C. Post-procedure confusion and memory loss are common and temporary side effects of ECT, lasting a few hours to days in some cases.
D. Voice changes are not associated with ECT. The procedure does not affect the vocal cords or speech.

A. A bologna sandwich on rye bread B. Whole wheat pasta with shrimp C. A corn tortilla with black beans D. Low sodium vegetable soup with barley

Correct Answer is C

Explanation

A. A bologna sandwich on rye bread. This is incorrect because rye bread contains gluten, which must be avoided in a celiac disease diet.
B. Whole wheat pasta with shrimp. This is incorrect because whole wheat pasta contains gluten, making it unsuitable for a child with celiac disease.
C. A corn tortilla with black beans. This is correct because corn tortillas are naturally gluten-free, and black beans provide a nutritious, safe option for a child with celiac disease.
D. Low sodium vegetable soup with barley. This is incorrect because barley contains gluten, making it inappropriate for a celiac-friendly diet.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?

Correct Answer is C

Explanation

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

Correct Answer is C

Explanation

A nurse is implementing crisis intervention for a client following an incident of partner violence. Which of the following is the priority action for the nurse to take?

A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like "something opened up." The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?

A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

A nurse is teaching a class of newly licensed nurses about infectious diseases that nurses are required to report to the health department. Which of the following diseases should the nurse include in the teaching?

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

A nurse is evaluating the progress of a school-age child who takes methylphenidate. Which of the following findings indicates the effectiveness of the medication?