Which of the following actions should the nurse take to redu...

A nurse in a long-term care facility is admitting a client with dementia.

Which of the following actions should the nurse take to reduce the risk for client injury?

A. Keep the television on during the night
B. Place the bedside table at the foot of the bed
C. Raise the side rails up when the client is in bed
D. Assist the client to the toilet frequently

Correct Answer: C

Rationale: The correct answer is C: Raise the side rails up when the client is in bed. This action helps prevent falls and injuries by providing a physical barrier to keep the client from rolling out of bed. Keeping the television on (choice A) does not directly address client safety. Placing the bedside table at the foot of the bed (choice B) may not prevent falls or injuries. Assisting the client to the toilet frequently (choice D) is important for personal care but does not directly reduce the risk for client injury.

A nurse caring for a client in the outpatient mental health clinic
Vital signs
2 months ago:
BP 128/78 mm Hg
Heart rate 76/min
Respiratory rate 17/min
Today
BP 169/91 mm HG
Heart rate 78/min
Respiratory rate 18/min
Nurses' Notes
Today
Client states, "I'm feeling much better." They report less fatigue, even though they have
difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent
headaches. Client continues to deny any suicidal ideation.

Select the findings that indicate the client is experiencing adverse effects of the medication.

A. Client states, 'I am feeling much better'
B. Difficulty sleeping
C. Client continues to deny any suicidal ideation
D. BP 169/91 mm HG
E. Respiratory rate 18/min

Correct Answer: B,D

Rationale: Hypertension and difficulty sleeping are potential side effects of certain medications.

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 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.

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 pregnant. 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.
Vital Signs Day
1, 0900:
Temperature (oral) 36.9°C (98,4° F) Heart
rate 72/min
Respiratory rate 16/min BP
162/112 mm Hg
Oxygen saturation 97% on room air
Diagnostic Results Day 1,
1000:
Appearance cloudy (clear) Color
yellow (yellow)
pH 5.9 (4.6 to 8)
Protein 3+ (negative)
Specific gravity 1.013 (1.005 to 1.03) Leukocyte esterase
negative (negative)
Nitrites negative (negative) Ketones
negative (negative) Crystals negative
(negative) Casts negative (negative)
Glucose trace (negative) WBC 5 (0
t0 4)
WBC casts none (none)
RBC 1 (less than or equal to 2) RBC
casts none (none)

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

A. Urine protein
B. Fetal activity
C. Blood pressure
D. Urine ketones
E. Respiratory rate
F. Report of headache
G. Gravida/parity

Correct Answer: A,C,F,G

Rationale: The correct answers (A, C, F, G) indicate potential prenatal complications. Urine protein (A) suggests preeclampsia, a serious condition characterized by high blood pressure (C) and proteinuria. Headaches (F) can also be a sign of preeclampsia. Gravida/parity (G) provides important obstetric history, identifying high-risk pregnancies. Fetal activity (B) and respiratory rate (E) are not specific to prenatal complications. Urine ketones (D) may indicate dehydration but not necessarily a prenatal complication.