The nurse continues to care for the client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Urine culture

Vaginal culture

Ibuprofen 600 mg every 6 hr for mild to moderate pain

Obtain provider prescription for phenazopyridine

Obtain provider prescription for antibiotics

Answer and Explanation

Correct Answer : A,B,D,E

A. Urine culture: The client has fever (38.4°C), dysuria, leukocyte esterase, and WBC casts in the urine, suggesting a urinary tract infection (UTI) or pyelonephritis. A urine culture is necessary to identify the causative organism and guide antibiotic therapy.
B. Vaginal culture: The client has preterm contractions and a history of preterm birth. Infections (e.g., bacterial vaginosis, Group B Streptococcus, sexually transmitted infections) can trigger preterm labor. A vaginal culture can help determine if an infection is contributing to labor symptoms.
C. Ibuprofen 600 mg every 6 hr for mild to moderate pain: NSAIDs (e.g., ibuprofen) are contraindicated in pregnancy after 30 weeks gestation because they can cause premature closure of the ductus arteriosus, leading to fetal circulation issues and increase the risk of oligohydramnios (low amniotic fluid levels) by reducing fetal kidney function. Instead, acetaminophen (Tylenol) is preferred for pain relief in pregnant clients.
D. Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic used to relieve dysuria and bladder discomfort. This medication does not treat the infection but provides symptomatic relief while waiting for antibiotics to take effect.
E. Obtain provider prescription for antibiotics: The presence of WBC casts, fever, and positive leukocyte esterase suggests a UTI, possibly progressing to pyelonephritis. Prompt antibiotic therapy is critical to prevent complications such as preterm labor, maternal sepsis, or fetal distress.

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

Explanation

A. Blood pressure (90/50 mm Hg): Indicates hypotension, possibly due to gastrointestinal (GI) bleeding. This can compromise perfusion and requires immediate intervention.
B. Hemoglobin and hematocrit (Hgb 9.1 g/dL, Hct 27%): Suggests significant anemia, likely from chronic GI blood loss due to NSAID-induced gastric ulcer or H. pylori infection.
C. Current medications (Diclofenac 100 mg daily): NSAIDs (e.g., diclofenac) are known to cause gastric irritation, ulcers, and GI bleeding, especially in a client with H. pylori positivity.
D. WBC count (6,700/mm³): Normal, no signs of infection or acute inflammatory response.
E. Stool results (Hemoccult positive): Indicates GI bleeding, which, along with anemia and hypotension, suggests ongoing blood loss that needs urgent evaluation.
F. Heart rate (118/min): Tachycardia is a compensatory response to hypotension and blood loss, signaling hemodynamic instability.
G. Respiratory rate (18/min): Normal, no respiratory distress or signs of hypoxia.
H. Temperature (37.5°C/99.5°F) – Mildly elevated but not concerning in this context.

A. Document the client's condition every 15 min. B. Remove the client's restraint every 4 hr. C. Request a PRN restraint prescription for clients who are aggressive. D. Attach the restraint to the bed's side rails.

Correct Answer is B

Explanation

A. Documenting the client's condition every 15 minutes is too frequent for standard restraint protocols.
B. Protocols typically require that restraints be removed at least every 2–4 hours for assessment of the client's condition, skin integrity, and to provide a period of unrestrained movement.
C. PRN restraint prescriptions are not standard practice; restraints should be prescribed only when absolutely necessary and under strict guidelines.
D. Restraints should be attached to the bed frame or other secure point, not the side rails, to ensure safety and prevent injury.

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The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is B

Explanation

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The nurse continues to care for the client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.