A term multigravida, who is receiving oxytocin IV for labor augmentation, is requesting pain medication. Review of the client's record indicates that she was medicated 30 minutes ago with butorphanol 2 mg and promethazine 25 mg IV push. Vaginal examination reveals that the client's cervical dilation is 3 cm, 10% eﬀaced, and at a 0 station. Which action should the practical nurse (PN) implement?

Coach the client to take slow, deep breaths during each contraction.

Report to the nurse that the client needs another dose of butorphanol.

Notify the healthcare provider.

Discontinue the oxytocin infusion.

Answer and Explanation

The Correct Answer is A

In this situation, the practical nurse (PN) should coach the client to take slow, deep breaths during each contraction. The client has already been medicated with butorphanol and promethazine for pain relief and it may not be appropriate to administer another dose at this time. Instead, the PN can provide non- pharmacological pain relief measures such as coaching the client to use breathing techniques to help manage the pain during contractions. The other actions listed may also be appropriate in some situations, but coaching the client to use breathing techniques is the most appropriate action in this situation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.

A. Explain the unit rules to ensure his safety. B. Gather required admission information. C. Have the client put personal items away. D. Sit and oﬀer to listen to the client's concerns.

Correct Answer is D

Explanation

The first intervention the PN should implement is to **sit and oﬀer to listen to the client's concerns**. It is important to approach the client in a calm and non-threatening manner and to establish a rapport with him. Oﬀering to listen to his concerns can help the client feel heard and understood, and can help build trust between the client and the PN.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention should the PN implement?

Correct Answer is C

Explanation

A male client with paranoia has been admitted to the mental health unit, and upon arrival, he immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

Correct Answer is D

Explanation

A client who is a primigravida at 40 weeks gestation is contracting every 2 minutes and her cervix is 9 cm dilated and 100% eﬀaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the practical nurse (PN) implement?

The practical nurse (PN) is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the PN take?

The practical nurse (PN) is caring for a client who has been diagnosed with gestational diabetes mellitus. Which complication should the PN recognize as the greatest risk to the fetus if euglycemia is not maintained?

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the practical nurse (PN) use to demonstrate support of the client?

A 4-year-old girl is brought to the emergency room with a fractured arm. Which information should be a basis for the practical nurse (PN) to suspect child abuse?

A highly successful businessman presents to a mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

The client tells the practical nurse (PN), "I have been applying triple antibiotic ointment to my athlete's foot for the past two days, but it still itches." How should the PN respond?

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the practical nurse (PN) to ask?