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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Answers: Hypoxemia; Oxygen saturation

Rationale:

Hypoxemia: The client’s oxygen saturation is 88% on room air, which is below the normal range (≥ 95%). Hypoxemia is the most immediate and life-threatening concern as it affects oxygen delivery to vital organs.

Oxygen saturation: Low oxygen saturation is a direct indicator of impaired gas exchange, commonly seen in conditions like pneumonia. The priority intervention is to improve oxygenation, as outlined in the provider's prescription to administer oxygen at 2 L/min via nasal cannula.

A. Perform chest percussion and vibration. B. Place the client in a supine position. C. Instruct the client to perform diaphragmatic breathing. D. Assess the client's breath sounds. E. Restrict the client's fluid intake. F. Increase oxygen flow rate to 4 L/m

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

Explanation

A. Perform chest percussion and vibration. Chest percussion and vibration help loosen and mobilize mucus in the airways, which is essential for clients with productive cough and a history of smoking-related respiratory issues. This intervention facilitates effective expectoration and improves breathing.

B. Place the client in a supine position. Placing the client in a supine position can worsen shortness of breath, especially in individuals with respiratory distress. The client should be positioned upright or in a high-Fowler's position to facilitate lung expansion.

C. Instruct the client to perform diaphragmatic breathing. Diaphragmatic breathing helps improve lung expansion, reduce the work of breathing, and promote relaxation. This technique is particularly useful for clients with an irregular breathing pattern and anxiety.

D. Assess the client's breath sounds. Continuous assessment of breath sounds is critical to monitor the effectiveness of interventions, such as oxygen therapy and nebulization, and to detect any worsening of respiratory status.

E. Restrict the client's fluid intake. Fluid intake should not be restricted unless contraindicated, as hydration helps thin mucus, making it easier to expectorate. This is particularly important for clients with a productive cough.

F. Increase oxygen flow rate to 4 L/min. Increasing the oxygen flow rate beyond 2 L/min requires caution in clients with chronic obstructive pulmonary disease (COPD) or similar conditions, as higher oxygen levels can suppress their respiratory drive. Oxygen therapy should be titrated carefully based on the provider's prescription and monitoring of oxygen saturation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in the emergency department (ED) is admitting a client. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's ___1___ evidenced by the client's ___2___.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

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

Explanation

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