A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Instruct the client to be NPO for six hours prior to the procedure

Instruct the client to maintain a full bladder for the procedure

Monitor the fetal heart rate prior to the procedure.

Place the client in Trendelenburg position during the procedure

Answer and Explanation

The Correct Answer is C

Rationale:

A. Instruct the client to be NPO for six hours prior to the procedure: Amniocentesis is typically done under local anesthesia and does not require sedation or general anesthesia, so there is no need for the client to be NPO beforehand.

B. Instruct the client to maintain a full bladder for the procedure: A full bladder is required during early pregnancy to help lift the uterus for better visualization. However, at 22 weeks gestation, the uterus is already an abdominal organ, and a full bladder is not necessary.

C. Monitor the fetal heart rate prior to the procedure: Monitoring the fetal heart rate before an amniocentesis is essential to establish a baseline and ensure fetal well-being. It also aids in identifying any immediate changes following the procedure.

D. Place the client in Trendelenburg position during the procedure: The Trendelenburg position is not appropriate for amniocentesis. The client is typically placed in a supine or slightly tilted position to allow proper access to the uterus and avoid vena cava compression.

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Correct Answer is ["B","C","E"]

Explanation

Rationale for Correct Findings:

Productive cough: In a client with COPD and recent MI, this may signal infection or fluid overload, especially if paired with fever, dyspnea, and hypoxia. Immediate assessment is needed to rule out pneumonia or heart failure.
Shortness of breath and chest pain with ambulation: This raises concern for myocardial ischemia, reinfarction, or worsening heart function. Chest pain with minimal exertion post-MI demands prompt evaluation and possible ECG and oxygen therapy.
Anxiety and fear of dying: Sudden intense fear may indicate worsening hypoxia, cardiac distress, or even be a prodrome to another MI. It should not be dismissed as purely psychological, especially in the context of other concerning symptoms.

Rationale for Incorrect Findings:

Pain rated 3/10: A mild pain score suggests the discomfort is currently manageable. While chest pain after MI is always important, this level does not in itself indicate an emergency unless it worsens or is unrelieved.
Oriented to room: Being alert and oriented indicates preserved cognition and neurologic stability. No immediate follow-up is needed based on this observation.

A. Respite care B. Adult day care C. Medicare Part A D. Medicaid E. Food Stamps

Correct Answer is ["D","E"]

Explanation

Rationale:

A. Respite care: Respite care is designed to temporarily relieve caregivers of people with chronic conditions, typically elderly or disabled clients. It is not suitable for a young adult needing home IV therapy unless there is a primary caregiver experiencing burnout, which is not indicated in this scenario.

B. Adult day care: Adult day care services are intended for older adults who need supervision and social interaction during daytime hours. This service is not relevant for a young adult receiving home-based IV therapy, which requires in-home clinical support rather than daytime supervision outside the home.

C. Medicare Part A: Medicare Part A covers hospital stays, skilled nursing, and limited home health services but is generally for individuals over 65 or those with qualifying disabilities. A young adult living in poverty without a qualifying disability would not typically be eligible for this benefit.

D. Medicaid: Medicaid provides comprehensive health coverage for low-income individuals of all ages and is often used to fund home healthcare services, including IV therapy. It is a key resource for ensuring this client receives needed care at home.

E. Food Stamps: The Supplemental Nutrition Assistance Program (SNAP), commonly known as Food Stamps, helps low-income individuals afford adequate nutrition. This support is crucial for clients below the poverty level, especially while recovering and managing ongoing healthcare needs.

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A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E"]

Explanation

A nurse is collaborating with social services in the discharge planning for a young adult client who is below the poverty income level and will require home V therapy. Which of the following resources should the nurse recommend? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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