A nurse is caring for a client.

Exhibits

A nurse is continuing care for the client.

For each potential nursing action, click to specify if the nursing action is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Obtain consent for cesarean birth

Provide intermittent fetal heart rate monitoring

Administer oxygen 10 L via face mask

Prepare the client for an amnioinfusion

Initiate IV bolus lactated Ringer’s

Insert a urinary catheter

Answer and Explanation

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

Nursing action	Anticipated	Contraindicated
Obtain consent for cesarean birth	✅
Provide intermittent fetal heart rate monitoring	✅
Administer oxygen 10 L via face mask	✅
Prepare the client for an amnioinfusion		✅
Initiate IV bolus lactated Ringer’s	✅
Insert a urinary catheter		✅

Rationale:

Obtain consent for cesarean birth: This is anticipated because the client is presenting with uterine contractions, vaginal bleeding, and abdominal pain, which may indicate complications such as placental abruption or abnormal placental attachment, potentially requiring a cesarean birth for the safety of both the mother and fetus.

Provide intermittent fetal heart rate monitoring: This is anticipated as it is essential to monitor fetal well-being, especially with the reported minimal fetal heart rate variability and potential for fetal distress.

Administer oxygen 10 L via face mask: This is anticipated to improve oxygenation, especially if there is a risk of fetal distress or compromised perfusion due to maternal blood loss.

Prepare the client for an amnioinfusion: This is contraindicated in the setting of vaginal bleeding and suspected placental abruption, as amnioinfusion is typically used for conditions such as oligohydramnios, and it could increase the risk of additional complications in this case.

Initiate IV bolus lactated Ringer’s: This is anticipated as the client has signs of hypovolemic shock due to blood loss, and an IV bolus would be necessary to improve fluid volume and blood pressure.

Insert a urinary catheter: This is contraindicated unless clinically necessary, as urinary catheterization may not be indicated in the immediate management of placental issues or bleeding complications without further evaluation, and it could introduce an infection risk.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. Place a nonadherent dressing on the right knee abrasion: While minor abrasions should be cleaned and dressed, it is not a priority compared to managing the child's pain and fracture care.

B. Administer Ibuprofen 200 mg: Ibuprofen is an appropriate analgesic and anti-inflammatory medication to manage the child's pain (rated 5/10) and reduce swelling. Prompt pain relief is essential for the child’s comfort.

C. Apply ice packs to the fingers and along the right forearm: Applying ice helps reduce edema, pain, and inflammation at the fracture site. It also minimizes soft tissue damage.

D. Elevate the affected forearm with pillows: Elevating the arm helps reduce swelling and promotes venous return, which is essential for minimizing discomfort and preventing complications like compartment syndrome.

E. Review cast care instructions with the child's parents: Reviewing cast care is essential but should be done after the cast is applied, not at this stage of care.

F. Explain the cast application procedure to the child: This is important but not an immediate priority. The nurse should first address pain, swelling, and proper limb positioning before discussing the procedure.

A. Weight gain B. Shuffling gait C. Dry mouth D. Sedation

Correct Answer is B

Explanation

A. Weight gain is a common side effect but does not require immediate reporting unless significant.

B. Shuffling gait is a sign of extrapyramidal symptoms (EPS), which can lead to tardive dyskinesia and requires prompt evaluation.

C. Dry mouth is a common side effect and can be managed with increased fluid intake or sugar-free candy.

D. Sedation is a common side effect but is not typically a reason to contact the provider unless it significantly impacts daily activities.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 9-year-old child at a clinic. Exhibits Select the 3 priority actions that the nurse should take.

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

Explanation

A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

Correct Answer is B

Explanation

A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

A nurse is assessing a client following an esophagogastroduodenoscopy. Which of the following findings should the nurse report to the provider?

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?