A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who received a pain medication 30 min ago for postoperative pain

A client who was just given a glass of orange juice for a low blood glucose level

A client who has 100 mL of fluid remaining in his IV bag

A client who is scheduled for a procedure in 1 hr

Answer and Explanation

The Correct Answer is B

A.   A client who has recently received pain medication should be assessed for effectiveness but is not in immediate danger.
B.   A client who received orange juice for a low blood glucose level needs to be assessed for a return to normal glucose levels as hypoglycemia is a priority concern.
C.   A client with 100 mL of fluid remaining in the IV bag can wait for assessment as their fluid needs can be managed once the infusion is complete.
D.   A client scheduled for a procedure in 1 hour is important to assess, but their immediate clinical needs may be less critical than a client with hypoglycemia.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

1. Administer oxytocin
Unanticipated: Oxytocin is typically used to induce labor or augment labor by stimulating uterine contractions. Since the client is already experiencing preterm labor, administering oxytocin could exacerbate contractions, leading to a more rapid progression of labor, which is not desired at 33 weeks gestation.
2. Administer terbutaline
Anticipated: Terbutaline is a tocolytic agent used to stop preterm labor by relaxing the uterus and inhibiting contractions. Given that the client is experiencing preterm labor (with regular contractions), this medication would be used to attempt to stop labor and delay delivery, which is an appropriate action for a 33-week pregnant client with early labor signs.

3. Administer betamethasone
Anticipated: Betamethasone is a corticosteroid that promotes lung maturity in preterm infants. At 33 weeks gestation, it is common to administer betamethasone if preterm labor is suspected, as it enhances fetal lung development and reduces the risk of respiratory distress syndrome in the newborn.
4. Maintain bed rest with bathroom privileges
Anticipated: Bed rest is often recommended for clients with preterm labor to reduce uterine activity and promote fetal well-being. While some studies suggest limited benefits, it is still a common non- pharmacological approach to manage preterm labor and reduce the risk of premature delivery.
5. Limit fluid intake to 3,000 mL/day
Unanticipated: There is no indication that the client is at risk for fluid overload or hyponatremia (which would require fluid restriction). In fact, hydration is often encouraged in preterm labor to prevent dehydration, which can worsen uterine contractions.
6. Place client in supine position
Unanticipated: Supine position is not recommended during pregnancy, particularly after the first trimester, due to the risk of supine hypotensive syndrome (compression of the vena cava, leading to reduced blood flow to the uterus and fetus). In fact, lateral positioning (e.g., left side-lying) is recommended for optimal circulation.

A. Assess for skin necrosis. B. Educate the family to avoid sharing personal belongings. C. Administer antitoxin. D. Ensure the state health department has been notified.

Correct Answer is A

Explanation

A. Assessing for the characteristic erythema migrans (bullseye rash) and other manifestations of Lyme disease is important for early detection and treatment.
B. Lyme disease is not contagious and does not require isolation or restrictions on sharing personal belongings.
C. Antitoxin is not used for Lyme disease; antibiotics are the primary treatment.
D. While Lyme disease should be reported, it is not a mandatory report to the state health department unless there is an outbreak or specific reporting requirements.

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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For each potential provider's prescription, click to specify if the potential prescription is anticipated or unanticipated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

Correct Answer is A

Explanation

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