The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Repeat quantitative B-hCG level

Methotrexate IM

Blood typing

Cervical cerclage

Transvaginal ultrasound

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

• Repeat quantitative B-hCG level: Monitoring the trend of quantitative beta-hCG levels is crucial in suspected ectopic pregnancy. Falling or plateauing hCG levels confirm the diagnosis and guide the management plan, especially if methotrexate is administered or surgical intervention is considered.

• Methotrexate IM: Methotrexate is an anticipated prescription for the medical management of a stable ectopic pregnancy. It works by stopping the growth of rapidly dividing cells and is appropriate when the client is hemodynamically stable and the ectopic pregnancy is unruptured.

• Blood typing: Blood typing is essential to determine Rh factor status. If the client is Rh-negative, Rh immune globulin should be administered to prevent isoimmunization, which could impact future pregnancies. This is a standard part of the care plan for any pregnancy loss or threatened pregnancy complication.

• Transvaginal ultrasound: A transvaginal ultrasound is needed to confirm the location of the pregnancy. In ectopic pregnancies, it helps visualize the presence or absence of an intrauterine gestational sac and may directly identify ectopic implantation, such as in the fallopian tube.

• Cervical cerclage: Cervical cerclage is contraindicated in this case. It is used to prevent preterm birth in clients with cervical insufficiency but is not appropriate in a non-viable pregnancy or suspected ectopic pregnancy. Placing a cerclage could worsen the clinical situation and delay necessary treatment.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Ask the client's family about cultural or religious practices regarding postmortem care: Respecting the client's and family's cultural and religious preferences is an important aspect of providing dignified and individualized postmortem care. Some practices may have specific rituals that should be honored.

B. Remove the client's dentures from their mouth before rigor mortis begins: Dentures are usually placed back into the client's mouth, not removed, to maintain a natural facial appearance and support the facial structure before rigor mortis sets in.

C. Turn on all the lights in the room before the family views the client's body: Creating a calm, peaceful environment is preferred when the family views the body. Harsh lighting may feel overwhelming or intrusive during such an emotional time.

D. Position the client's bed flat without a pillow under their head: Elevating the head of the bed slightly and placing a pillow under the head can help prevent blood from pooling in the head and face, preserving a more natural appearance. Leaving the bed flat is not ideal.

A. Limit periods of sitting in a chair to 4 hr. B. Avoid the use of draw sheets for repositioning C. Use a no-rinse perineal cleanser after incontinence. D. Keep the head of the client's bed elevated to 45.

Correct Answer is C

Explanation

A. Limit periods of sitting in a chair to 4 hr: Clients with urinary incontinence should avoid prolonged sitting because it increases pressure on the skin and raises the risk of skin breakdown. Sitting should be limited to shorter periods with frequent repositioning to protect skin integrity.

B. Avoid the use of draw sheets for repositioning: Draw sheets are helpful for repositioning clients safely and reducing friction and shear forces on the skin. Avoiding their use would increase the risk of skin injury, especially in clients with incontinence who are already vulnerable.

C. Use a no-rinse perineal cleanser after incontinence: Using a no-rinse perineal cleanser helps maintain skin hygiene, removes urine and feces gently, and prevents irritation or breakdown. It is an important part of incontinence care to protect the client's skin health.

D. Keep the head of the client's bed elevated to 45º: Elevating the head of the bed to 45º degrees is helpful for respiratory support but does not directly address urinary incontinence. Bed positioning should be adjusted based on overall client needs, not specifically to manage incontinence.

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse's priority to report to the provider?

A nurse is assisting with the care of a client. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume overload?

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the low in potassium?

A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.