A nurse is caring for a client who is pregnant.

Complete the following sentence by using the lists of options.

The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should first assist with is
_
followed by
_

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Reviewing fetal heart rate tracing: Reviewing the fetal heart rate tracing is the first action because the client has signs of severe preeclampsia, which can quickly lead to fetal distress. The fetal monitor will provide immediate information about the baby’s oxygenation status. Detecting any late decelerations or bradycardia would require urgent intervention to protect fetal life.
Administering IM betamethasone: Administering IM betamethasone is important to accelerate fetal lung maturity in case early delivery is necessary. Since the client is only at 31 weeks, promoting lung development is crucial to improve neonatal outcomes. However, confirming fetal well-being comes first before giving medications.
Scheduling an emergency cesarean section: An emergency cesarean section is not the first step without evidence of fetal compromise or maternal instability. At this point, the fetal heart rate shows moderate variability and accelerations, which are reassuring. A cesarean is only scheduled if fetal distress or worsening maternal condition occurs after further monitoring.
Insert a Foley catheter to monitor urine output: Inserting a Foley catheter is important to monitor kidney function and fluid status in preeclampsia. Reduced urine output can signal worsening disease. However, it is not the priority over assessing the fetal condition first, because fetal distress can occur rapidly and needs immediate identification.
Administering antibiotics: There is no current indication for administering antibiotics based on the client's data. The client does not have signs of infection, such as fever, elevated WBCs, or positive urinalysis for infection. Administering antibiotics would not address the current primary risks related to severe preeclampsia.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Encourage visits from family members: While family presence can help reduce anxiety and reorient clients with delirium, it is not the immediate first step. Before implementing supportive strategies, the nurse must first assess the client’s neurological status to determine the severity and possible cause of the delirium.

B. Administer an anxiolytic medication: Administering medications should not be the first action because delirium can be caused by multiple reversible factors. Sedating a client without identifying the underlying cause may worsen confusion or mask important symptoms that need immediate intervention.

C. Determine the client's level of consciousness: Assessing the client’s level of consciousness is the priority because it provides critical information about the severity of the delirium and helps guide immediate and appropriate interventions. Early assessment ensures that life-threatening conditions, such as hypoxia or sepsis, are not overlooked.

D. Keep lights on in the client's room: Maintaining a well-lit environment can help prevent disorientation, especially at night, but it is a secondary supportive measure. Assessment of mental status must occur first to prioritize safety and identify urgent medical needs.

A. Maintain 30 ml sterile water in the drainage collection chamber B. Place the drainage device level with the tube insertion site C. Keep system tubing connections taped together. D. Empty the drainage collection chamber every 4 hr.

Correct Answer is C

Explanation

A. Maintain 30 ml sterile water in the drainage collection chamber: The sterile water is maintained in the water-seal chamber, not the drainage collection chamber. The water-seal chamber typically holds about 2 cm of water to create a one-way valve preventing air from entering the pleural space, not 30 mL in the drainage area.

B. Place the drainage device level with the tube insertion site: The drainage device should always be kept below the level of the chest tube insertion site to allow gravity to assist drainage and to prevent backflow of fluid or air into the pleural cavity, which could cause complications.

C. Keep system tubing connections taped together: Taping the system tubing connections securely helps maintain a closed system, preventing accidental disconnections that could lead to air leaks or loss of the negative pressure needed for proper lung re-expansion. This is essential for the effectiveness of chest tube management.

D. Empty the drainage collection chamber every 4 hr: The drainage collection chamber is not emptied routinely. Instead, it is replaced when full or according to facility protocol. Frequent opening of the system increases the risk of introducing infection or losing the closed negative-pressure system.

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Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has a pleural chest tube with a closed drainage system. Which of the following actions should the nurse recommend for the client's care?

Correct Answer is C

Explanation

A nurse is assisting in the care of a group of clients. Which of the following occurrences should the nurse identify as requiring an incident report?

A male nurse is assigned to care for an older adult female client. The client tells the nurse that she wants a female nurse to care for her. Which of the following statements should the nurse make?

A nurse is assisting with the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse in a long-term care facility has just received change-of-shift report. Which of the following clients should the nurse attend to first?

The nurse is reviewing the findings. For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

A nurse is assisting with planning care for a client who has a new diagnosis of multiple sclerosis. Which of the interventions should the nurse recommend?

A nurse is reinforcing teaching with a group of clients about taking recommended folic acid supplements prior to conception and throughout pregnancy as primary prevention. Which of the following conditions can occur in the neonate as the result of folic acid deficiency?