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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.
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A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraint straps to the side rails of the bed.
- C. Use a square knot to secure the restraint.
- D. Ensure there is at least a 2-inch gap between the restraint and the client's body.
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial for monitoring the client's status, detecting any changes promptly, and ensuring their safety. Documenting every 15 minutes allows for timely intervention and assessment.
Choice B is incorrect because attaching restraint straps to the side rails can lead to entrapment and harm.
Choice C is incorrect as a square knot is not recommended for securing restraints due to the risk of difficulty in quick release during emergencies.
Choice D is incorrect as a 2-inch gap between the restraint and the client's body can increase the risk of injury or self-removal.
The nurse is continuing to care for the client. Nurses'
Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by
acetaminophen. Client also reports urinary frequency and decreased fetal movement.
Client is a G3 P2 with one preterm birth.
Day 1, 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies
visual disturbances, +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without
the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal
movements within the last 30 min. External fetal monitor applied with a baseline FHR 140/min
with occasional accelerations and moderate variability. No uterine contractions noted.
The nurse is initiating the client's plan of care. Which of the following Interventions should the
nurse plan to implement?
The nurse is initiating the client's plan of care. Which of the following Interventions should the nurse plan to implement?
- A. Provide a low-stimulation environment.
- B. Maintain bed rest.
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly.
- F. Obtain a 24 hr urine specimen.
- G. Perform a vaginal examination every 12 hr.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes providing a low-stimulation environment (A) for client comfort, maintaining bed rest (B) to promote healing, giving antihypertensive medication (C) for blood pressure management, administering betamethasone (D) for specific medical needs, monitoring intake and output hourly (E) for fluid balance assessment, and obtaining a 24 hr urine specimen (F) for diagnostic purposes. These interventions are essential in addressing the client's physical and physiological needs during care planning. Performing a vaginal examination every 12 hr (G) is not typically indicated and may not be necessary unless specifically ordered for a particular condition.
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia.
Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.
A nurse is caring for a client who has respiratory depression from an opioid administration.
After administering naloxone, which finding should the nurse expect?
- A. Somnolence
- B. Increased respiratory rate
- C. Sudden onset of pain or discomfort
- D. Hypertension and tachycardia
- E. Nausea and vomiting
Correct Answer: B
Rationale: After administering naloxone, the nurse should expect an increased respiratory rate. Naloxone is an opioid antagonist that reverses the effects of opioids, including respiratory depression. By blocking opioid receptors, naloxone can restore normal breathing patterns. Choices A (Somnolence), C (Sudden onset of pain or discomfort), D (Hypertension and tachycardia), and E (Nausea and vomiting) are incorrect because they are not typical findings after administering naloxone. Somnolence would not be expected as naloxone counteracts sedation caused by opioids. Sudden onset of pain or discomfort is unrelated to naloxone administration. Hypertension and tachycardia are more indicative of opioid overdose, which naloxone would mitigate. Nausea and vomiting are also not common side effects of naloxone.
A nurse is obtaining the temperature of a newborn.
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.