Try Naxlex NCLEX-RN (Free-Trial)

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The Patient Self-Determination Act (PSDA) requires health care facilities to ask clients about advance directives upon admission and document their status in the medical record. This ensures that the client’s treatment preferences are known and respected.
B. Ensuring the client has an attorney is not a requirement of the PSDA. Clients may choose legal assistance, but it is not mandated by the act.
C. Providing end-of-life education is beneficial but not specifically required by the PSDA. The act focuses on informing clients of their rights regarding advance directives.
D. The PSDA does not require facilities to provide a list of eligible health care proxies. Instead, it ensures clients are informed of their right to appoint one.

A. Insert an NG tube for a client who requires enteral feedings. B. Record a client's intake after each meal. C. Obtain a client's vital signs every 4 hr. D. Instruct a client on the use of an incentive spirometer. E. Transfer a client to physical therapy.

Correct Answer is ["B","C","E"]

Explanation

A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

Correct Answer is A

Explanation

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who has a terminal illness. The client tells the nurse, "I have decided to discontinue my treatment. I want to pursue alternative therapies instead." Which of the following responses should the nurse make?

A nurse is assessing a client who is in mechanical restraints after hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." Which of the following responses should the nurse make?

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 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?

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 in an antepartum unit is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.