A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back.
Which of the following actions should the nurse take?
Provide the client with a glass of orange juice.
Instruct the client to take a brisk walk.
Position the client on their left side.
Check the client's temperature.
The Correct Answer is C
Explanation
C. Position the client on their left side
The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.
Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.
Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.
Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.
Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.
Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation:
Bleach is an effective disinfectant for blood spills and is recommended by healthcare guidelines for its ability to kill a broad range of microorganisms, including bloodborne pathogens such as human immunodeficiency virus (HIV). To prepare a bleach solution, the nurse can mix 1-part bleach with 10 parts water. This diluted bleach solution can be used to clean and disinfect the overbed table surfaces that have been contaminated with blood.
A- Chlorhexidine is an antiseptic commonly used for skin preparation before invasive procedures, but it is not the ideal choice for disinfecting surfaces or objects after a blood spill.
B- Isopropyl alcohol is effective for disinfecting small surfaces, but it may not be as effective as bleach for blood spills, particularly in the context of bloodborne pathogens like HIV.
D- Hydrogen peroxide can be used as a disinfectant, but it may not be as effective as bleach in eliminating bloodborne pathogens from surfaces.
Correct Answer is B
Explanation
By using short, simple sentences, the nurse can effectively communicate with the client who is exhibiting signs of agitation and anxiety. This communication style can help reduce stress and confusion for the client and promote understanding.
Asking the client if they would like to watch television: While providing options for activities can be beneficial, it is important to address the client's current state of agitation and anxiety before suggesting any specific activities.
Allowing the client to have 1 hour of time alone in their room: While some clients may prefer solitude, in this case, the client's pacing and hand-wringing indicate signs of distress and may require therapeutic interventions rather than isolation.
Moving the client to a table where other clients are playing cards: This option may not address the client's current state of anxiety and pacing. Placing the client in a social setting with other clients might increase their distress and agitation.
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