The nurse is assisting in the care of the client who is at 30 weeks of gestation.

Nurses' Notes

1200:

Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.

Encouraged client to cough and take deep breaths regularly.

Assisted with insertion of 18-gauge IV and initiation of IV fluid.

Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict input/output monitoring; total intake 180 mL/hour.

FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.

1400:

Magnesium sulfate infusion ongoing.

Client is lethargic. Heart rate regular 58bpm, blood pressure 148/99 mmHg, respirations shallow DTR 1+ bilaterally.

Urine output 20 mL in the last hour

1405:

Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.

1800:

Client is alert and responsive. Heart rate regular 78bpm, respirations even and unlabored. DTR 2+ bilaterally

Oxygen saturation (SaO) 95% on 2 L nasal cannula. Respiratory rate 18/min. Blood pressure 146/96 mm Hg.

Select the findings that indicate the client's condition has improved.

Urine output 40 mL in the last hour

Temperature 38.3°C(101 F)

Blood pressure 146/96 mm Hg

Deep tendon reflexes 2+ bilaterally

Heart rate 78/min

Answer and Explanation

Correct Answer : D,E

Deep tendon reflexes (DTR): At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.

Heart rate: At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.

Other findings:

Urine output 40 mL in the last hour: Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.

Temperature 38.3°C (101°F): This indicates a fever, which is not a sign of improvement.

Blood pressure 146/96 mm Hg: Although this is better than a severely hypertensive reading, it is still elevated.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

A.Planning care, especially for a client with dysphagia (difficulty swallowing), involves assessment, evaluation, and critical thinking, which are within the scope of practice for licensed nurses, not APs. This task should not be delegated to an AP.

B.Transferring a client, especially one undergoing radiation therapy, often involves understanding specific precautions and handling techniques. This task is generally within the scope of APs, provided they have proper training and understand any specific precautions related to the client's condition.

C.Recording urine output is ataskthat can be delegated to an assistive personnel under the supervision of a registerednurse, as they do not require nursing judgment or assessment skills.

D.Measuring vital signs is a taskthat can be delegated to an assistive personnel under the supervision of a registered nurse, as they do not require nursing judgment or assessment skills.

A. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds B. Providing the client with information on community resources that will strengthen her coping skills C. Identifying the client's perception of the changes in her physical appearance D. Encouraging the client to write about her feelings in a journal each day

Correct Answer is C

Explanation

The correct answer is C. Identifying the client's perception of the changes in her physical appearance is essential for developing a plan of care that addresses her psychosocial needs and promotes her self-esteem and body image. The client may experience grief, anger, depression, anxiety, or guilt after losing her breasts, which can affect her quality of life and recovery. The nurse should explore how the client feels about herself and her sexuality, and provide emotional support and empathy. The other actions are also important, but they are not as a priority as understanding how the client views herself.

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Other findings:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client who is 2 days postoperative following a total bilateralmastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?

Correct Answer is C

Explanation

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take?

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?