The nurse continues to care for the client.

Nurses' Notes Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.
CBC and urinalysis collected and sent to lab. Day 1,0930:
Peripheral IV initiated. Provider prescriptions received and implemented. Day 1, 1000:
Client voided and reports pain and dicomfort upon urination. Client states, "I've noticed burning wife I urinate for the past 2 days."

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

Urine culture

Ibuprofen 600 mg every 6 hr for mild to moderate pain

Obtain provider prescription for phenazopyridine

Vaginal culture

Obtain provider prescription for antibiotics

Answer and Explanation

Correct Answer : A,C,E

A.   Urine culture: This will help identify the presence of any urinary tract infection (UTI) causing discomfort and burning during urination.
B.   Ibuprofen 600 mg every 6 hr for mild to moderate pain: While ibuprofen can help with pain relief, it does not address the potential underlying urinary tract infection, so it's important to address the infection first.
C.   Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can provide relief from the pain and discomfort associated with UTIs.
D.   Vaginal culture: The client's symptoms are related to discomfort and burning upon urination, suggesting a urinary tract issue rather than a vaginal issue. Therefore, a vaginal culture may not be relevant in this context.
E.   Obtain provider prescription for antibiotics: If a urinary tract infection is suspected based on the client's symptoms and urine culture results, antibiotics may be needed to treat the infection.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. A butterfly needle is not typically used for accessing implanted ports.

B. An angiocatheter is not typically used for accessing implanted ports.

C. A 25-gauge needle might be too small for accessing an implanted port.

D. Correct. A noncoring needle (Huber needle) is specifically designed for accessing implanted venous access ports to minimize damage to the port septum and prevent leakage.

A. Apply the largest cuff available. B. Place the arm above the level of the client's heart. C. Deflate the cuff quickly. D. Use the palpatory method to determine blood pressure.

Correct Answer is D

Explanation

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

Correct Answer is D

Explanation

A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

A nurse is assessing a client who is taking digoxin to treat chronic heart failure.Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

A nurse is assessing a client who is postoperative following orthopedic surgery.Which of the following findings should the nurse identify as an indication of paralytic ileus?

A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?

A client with Crohn's disease is preparing for discharge from the hospital following treatment for an exacerbation of diarrhea, abdominal pain, and rectal bleeding. Which dietary recommendation(s) should the nurse discuss with the client? (Select all that apply.)

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?