Nokea
Admission Assessment
Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant
medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4
on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior.
Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and
intact. Capillary refill less than 3 seconds. A 20-gauge IV saline lock inserted in back left hand
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
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The nurse is continuing to care for the client.
Provider Prescriptions Day 1,
1030
Admit to obstetrical unit.
Serum magnesium level per facility policy 24 hr urine
for total protein and creatinine Insert indwelling
urinary catheter Continuous external fetal monitoring
Administer loading dose of magnesium sulfate 4 g via Intermittent IV bolus over 20 min
followed by a maintenance dose of 2 g/hr
Lactated Ringer's 50 ml/tr via continuous iV infusion Betamethasone
12 mg IM X2 doses given 24 hr apart
Labetalol 20 mg IV bolus now, then 100 mg PO twice dally starting at 2000 Vital signs every 30
min
Acetaminophen 650 mg PO every 6 hr PRN pain Hourly intake and
output
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should take first is------followed by ----------
- A. evaluating the fetal heart rate tracing
- B. monitoring urine output
- C. Checking the client's blood pressure
- D. administering labetalol
- E. Starting the continuous IV infusion
- F. inserting an indwelling urinary catheter
Correct Answer: C,D
Rationale: The correct first action is to check the client's blood pressure (Choice C) as it is essential to assess the client's immediate physiological status. High blood pressure in obstetric patients can lead to severe complications. Administering labetalol (Choice D) is the next step if the blood pressure is elevated, as it is a commonly used medication to manage hypertension in pregnancy. Choices A, B, E, and F are important interventions but should be prioritized after addressing the client's blood pressure as they are not directly related to the immediate risk of hypertensive crisis.
A nurse is teaching a client about a variety of stress management techniques.
Which of the following instructions by the nurse is appropriate?
- A. Tighten your muscles before relaxing them when using muscle relaxation techniques
- B. Avoid deep breathing exercises, as they can increase stress.
- C. Focus on multiple thoughts at once to distract yourself from stress.
- D. Keep your emotions bottled up to maintain control over stress.
Correct Answer: A
Rationale: The correct answer is A because tightening muscles before relaxing them helps to enhance the effectiveness of muscle relaxation techniques by creating a greater sense of contrast between tension and relaxation. This sequence promotes deeper relaxation and can help reduce stress more effectively. Choice B is incorrect as deep breathing exercises are commonly used to reduce stress and promote relaxation. Choice C is incorrect as focusing on multiple thoughts at once can increase stress and overwhelm the individual. Choice D is incorrect as bottling up emotions can lead to increased stress and negatively impact mental health.
A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter.
Which action should the nurse take when working with the interpreter?
- A. Speak in a normal voice at a natural pace.
- B. Use medical jargon to ensure accuracy.
- C. Speak directly to the interpreter instead of the client.
- D. Ask the client to respond only with 'yes' or 'no' answers.
Correct Answer: A
Rationale: The correct answer is A: Speak in a normal voice at a natural pace. This is important because speaking clearly and at a natural pace allows the interpreter to accurately convey the message without missing any information. Using a normal voice also helps maintain a respectful and professional tone during communication.
Choice B is incorrect because using medical jargon may confuse the interpreter and lead to miscommunication. Choice C is incorrect as the nurse should always address the client directly to establish trust and rapport. Choice D is incorrect as it restricts the client's ability to express themselves fully.
A nurse is caring for a client who is one hour postpartum and unable to urinate.
Which of the following actions should the nurse take?
- A. Place the client's hand in warm water.
- B. Perform in-and-out catheterization.
- C. Encourage the client to void in the shower.
- D. Apply fundal pressure to stimulate urination.
Correct Answer: C
Rationale: The correct action is C: Encourage the client to void in the shower. This option promotes relaxation and can help facilitate urination. Warm water can help relax the muscles and promote voiding without invasive procedures like catheterization (B) or fundal pressure (D), which can be uncomfortable and potentially harmful. Voiding in the shower also maintains privacy and dignity for the client. Choices E, F, and G are not relevant to promoting urination.
A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-oid, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color.” Client also reports contractions began about 4 hr ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.