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.

Answer and Explanation

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).

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Correct Answer is ["C"]

Explanation

A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.

B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.

C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.

D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.

A. Allow a family member of the client to stay with the client's body until burial B. Position the client's head toward Mecca C. Allow a family member to stay with the client's body for 8 hr D. Position the client's head northward

Correct Answer is B

Explanation

In Islam, it is customary to position the deceased's head toward Mecca, which is considered the holiest city in Islam. Mecca is the direction toward which Muslims face during prayer. Orienting the client's head toward Mecca is a sign of respect for their religious beliefs and customs.

While it is common in some cultural and religious practices for family members to stay with the deceased until burial, this may vary depending on the specific beliefs and customs of the family. It is important to respect the family's wishes and cultural practices, but it is not solely specific to Islam.

The duration of time for a family member to stay with the deceased can vary depending on cultural and religious practices, but there is no specific set duration of 8 hours in Islamic customs.

In Islam, the direction of Mecca is significant, and positioning the client's head toward Mecca is the customary practice. There is no specific requirement to position the head northward in Islamic customs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is ["C"]

Explanation

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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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?