A client who is primigravida at term comes to the prenatal clinic and tells the practical nurse (PN) that she is having contractions every 5 minutes. The PN monitors the client for one hour using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. Which action should the PN take?

Tell the client to go directly to the hospital for admission to labor and delivery for active labor.

Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour.

Direct the client to check into the hospital within the next hour for evaluation of possible urinary tract infection.

Send the client home and tell her to drink at least 1,000 mL of fluid each day to flush her bladder.

Answer and Explanation

The Correct Answer is B

A. The client's contractions are not regular or intense enough to indicate active labor, so immediate hospital admission is not necessary.
B. Instructing the client to call the clinic when her contractions occur 5 minutes apart for one hour ensures she is monitored for the progression of labor and can seek timely assistance when labor becomes more active.
C. While a urinary tract infection could cause contractions, the primary focus should be on monitoring labor progression, not diagnosing a UTI at this stage.
D. Hydration is important, but the primary instruction should relate to monitoring contraction patterns for signs of active labor.

Nursing Test Bank

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

Explanation

A. Limiting fresh fruits and vegetables is not necessary for clients with ascites due to cirrhosis unless they are causing specific issues like bloating or discomfort. Fresh fruits and vegetables are generally healthy and can be part of a balanced diet unless restricted for other reasons.
B. Consuming concentrated sweets to boost energy is not a recommended dietary strategy for managing ascites or cirrhosis. This approach may lead to excessive calorie intake without addressing the nutritional needs for a balanced diet.
C. Eating six small meals daily can help manage low appetite and energy levels by providing consistent nutrition throughout the day. Small, frequent meals are easier to consume and can help maintain adequate caloric intake for individuals with low appetite.
D. Choosing small helpings from lean protein sources is a good suggestion for managing ascites and cirrhosis. Lean proteins are important for maintaining muscle mass and supporting overall health without exacerbating liver disease.
E. Avoiding adding salt to foods helps manage fluid retention associated with ascites. Reducing sodium intake is crucial for managing ascites and preventing further fluid accumulation.

A. A client who needs to ambulate to the bathroom for the first time since the birth of her infant. B. A client prepared for discharge who has a question about the teaching she received the day before. C. A client with twins who is tired and would like her babies returned to the newborn nursery. D. A post cesarean client with a prescription to have her indwelling urinary and intravenous

Correct Answer is A

Explanation

A. A client who needs to ambulate for the first time since delivery requires the PN’s immediate attention to ensure safety and prevent complications such as orthostatic hypotension or falls.
B. A client prepared for discharge who has a question about teaching is important but does not take precedence over immediate safety concerns related to the client’s physical activity.
C. A tired client with twins who would like her babies returned to the nursery is important for the client’s well-being, but it is not as urgent as ensuring the safety of a postpartum client beginning to ambulate.
D. Removing indwelling urinary and intravenous catheters is important but not as urgent as ensuring the safety of a client ambulating for the first time after birth.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

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

Explanation

The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

Correct Answer is A

Explanation

Exhibits The practical nurse (PN) re-educates the client on methicillin-resistant Staphylococcus aureus (MRSA). Click to indicate whether the client's statement(s) indicate understanding or no understanding. Each row must have one option selected.

When the practical nurse (PN) prepares to transfer a 12-hour-old newborn from the birthing suite to the nursery, which question is most important for the PN to ask the mother?

The practical nurse (PN) is assisting the recreational director of a long-term care facility plan outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

Exhibits The practical nurse (PN) notifies the healthcare provider that the client continues to have signs of fluid volume deficit. The health care provider prescribes a continuous infusion of isotonic fluids. Which fluid(s) is/are classified as isotonic? Select all that apply.

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) obtain a client's vital signs. The PN should intervene when observing the UAP performing which technique?

The practical nurse (PN) is reviewing home care instructions with the mother of a young girl with a urinary tract infection (UTI). Which information reported by the mother demonstrates understanding of home care for the child?

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN, "Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?