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":"A","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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Perfectionistic: Perfectionism is more characteristic of obsessive-compulsive personality disorder, where individuals are overly focused on order, control, and achieving flawless standards. Clients with dependent personality disorder are more focused on relying on others for decision-making rather than striving for perfection.

B. Reclusive: Being reclusive, or socially withdrawn, is a common feature of avoidant personality disorder, not dependent personality disorder. Clients with dependent personality disorder typically seek out and maintain close relationships because they have an intense fear of being alone and unable to care for themselves.

C. Impulsive: Impulsivity is commonly associated with borderline personality disorder, where individuals act without considering consequences. Clients with dependent personality disorder tend to be cautious and overly reliant on others for guidance and approval, rather than acting impulsively on their own.

D. Submissive: Submissiveness is a hallmark of dependent personality disorder. Clients demonstrate extreme dependency on others for emotional and decision-making support, often avoiding disagreement and putting others' needs above their own to maintain relationships and avoid abandonment.

A. The restraint is attached to the side rails of the bed. B. The restraint the strap is tied into a knot. C. The nurse can insert two fingers under the restraint. D. The skin under the restraint is cool and has changed color.

Correct Answer is C

Explanation

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

Correct Answer is C

Explanation

A nurse is assisting in the care of an adolescent. The nurse is reviewing the data collection findings. Select the 5 findings the nurse should report to the provider.

A nurse is reinforcing teaching for a client regarding long-acting reversible contraception options. Which of the following client statements indicate an understanding of the teaching?

A nurse is collecting data from a client about range-of-motion for various joints. Which of the following images should the nurse identity as an example of a ball and socket joint?

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

A nurse is using the assistance of an interpreter to reinforce discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take when working with an interpreter?

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 the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (APIT

A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the take prior to administering this medication?