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The nurse continues to care for the client.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.

Assessment

Findings

Nurses' Notes

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.

Membranes intact

No uterine contractions noted.

FHR baseline 138, minimal variability.

No further reports of burning with urination.

Laboratory Results

WBC 12, 000/mm3 (5000 to 10000/mm3)

Platelet count 188000/mm3 (150000 to 400000/mm3)

Vital Signs

Temperature 37.1°C (98.7°F)

Blood pressure 120/78 mmHg

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge

Membranes intact

No uterine contractions noted

FHR baseline 138, minimal variability

No further reports of burning with urination

WBC 12, 000/mm3 (5000 to 10000/mm3)

Platelet count 188000/mm3 (150000 to 400000/mm3)

Temperature 37.1<strong>°</strong>C (98.7<strong>°</strong>F)

Blood pressure 120/78 mmHg

Answer and Explanation

The Correct Answer is ["A","C","E","F","H","I"]

Nurses' Notes:

Client rates lower back pain a 0 on a scale from 0 to 10: Indicates pain resolution, suggesting improvement.

No reports of vaginal discharge: Suggests stabilization and no signs of labor progression.

No uterine contractions noted: Indicates that preterm labor is resolving.

No further reports of burning with urination: Suggests that the urinary tract infection (UTI) is improving.

Vital Signs:

Temperature 37.1°C (98.7°F): Fever has resolved, indicating response to antibiotics.

Blood pressure 120/78 mmHg: Remains stable within normal limits.

Laboratory Results:

WBC 12,000/mm³ (previously 16,000/mm³): Decreasing WBC count suggests resolution of infection.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Medications can typically be given within a 30-minute window before or after the scheduled time to maintain therapeutic levels.
B. While some medications have a grace period after the scheduled time, it is generally not recommended to delay vancomycin for 2 hours.
C. Vancomycin should be infused over at least 60 minutes to prevent "Red Man Syndrome" and nephrotoxicity.
D. Medications, especially antibiotics, should be given as scheduled to ensure efficacy.

Correct Answer is []

Explanation

Potential Condition: Gout

Actions to take:

Instruct the client to avoid foods high in purines

Instruct the client to apply heat and cold

Parameters to monitor

Uric Acid levels

ESR

Rationale:

Gout: Elevated uric acid level (7.2 mg/dL) suggests hyperuricemia, a key indicator of gout. Localized joint pain and crepitus in the right knee and left wrist are common gout symptoms. Family history of gout increases the client's risk. Negative ANA test and normal ESR make autoimmune conditions (RA, SLE) less likely.

Actions to Take:

Instruct the client to avoid foods high in purines: High-purine foods (e.g., red meat, seafood, alcohol) increase uric acid production, worsening gout attacks.

Instruct the client to apply heat and cold: Cold helps reduce inflammation and pain during acute flare-ups, while heat can ease stiffness between episodes.

Parameters to Monitor:

Uric acid levels: Monitoring serum uric acid helps assess treatment effectiveness and risk for future attacks.

ESR (Erythrocyte Sedimentation Rate): Elevated ESR can indicate ongoing inflammation. Tracking it helps evaluate disease activity and response to interventions.

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Assessment	Findings
Nurses' Notes	Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. FHR baseline 138, minimal variability. No further reports of burning with urination.
Laboratory Results	WBC 12, 000/mm3 (5000 to 10000/mm3) Platelet count 188000/mm3 (150000 to 400000/mm3)
Vital Signs	Temperature 37.1°C (98.7°F) Blood pressure 120/78 mmHg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse in an outpatient clinic. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A nurse is caring for a client who is postoperative following a right hip arthroplasty. Exhibits For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each finding may support more than 1 disease process.

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A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?

A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

A nurse is caring for a postpartum client in an outpatient setting. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdownevidenced by the client'sdropdown.

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