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A nurse in an antepartum unit is caring for a client.

Exhibits

Click to highlight the findings that indicate the interventions have been effective. To deselect a finding, click on the finding again.

Nurses' Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

Client rates pain with contractions as a 3 on a scale of 0 to 10

FHR 150/min with moderate variability. Accelerations present, no decelerations noted

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is E,C,D,A,B

Explanation

Verify the clarity and color of the eye drops. Ensuring the medication is not expired or contaminated is the first step in safe administration.
Tilt the client's head backward toward the ceiling. This position helps prevent the drops from draining out of the eye.
Pull the client's lower lid down with the nondominant hand. This creates a small pocket for the eye drops to be instilled properly.
Administer the prescribed number of drops. The medication should be placed in the conjunctival sac, not directly on the cornea.
Apply gentle pressure to the client's punctum. This prevents systemic absorption by blocking the nasolacrimal duct and reduces systemic side effects.

A. Polyuria B. Fever C. Diarrhea D. Diaphoresis

Correct Answer is B

Explanation

A. Polyuria. Increased urination is not a common adverse effect of clozapine and does not require immediate reporting.
B. Fever. Clozapine can cause agranulocytosis, a serious condition that suppresses white blood cell production. Fever may indicate infection, which requires immediate evaluation.
C. Diarrhea. Gastrointestinal symptoms can occur with clozapine but are not typically urgent unless severe or persistent.
D. Diaphoresis. Excessive sweating is a possible side effect but does not require immediate medical attention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is E,C,D,A,B

Explanation

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over- the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?

A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse include in the plan?

A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?

A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?