A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back.

Which of the following actions should the nurse take?

Provide the client with a glass of orange juice.

Instruct the client to take a brisk walk.

Position the client on their left side.

Check the client's temperature.

Answer and Explanation

The Correct Answer is C

Explanation

C. Position the client on their left side

The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.

Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.

Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.

Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.

Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.

Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).

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Correct Answer is A

Explanation

Promoting trust involves actions that build a sense of trust and rapport between the nurse and the client. In this scenario, the nurse recognizes the client's basic need for food and responds to it promptly and compassionately. By interrupting the bath to address the client's hunger, the nurse demonstrates attentiveness and care, which helps establish trust between the nurse and the client.

Countertransference refers to the nurse's emotional reaction or response to the client, which may be based on the nurse's personal experiences or unresolved issues. It does not apply to the nurse's action of obtaining a meal for the client.

Veracity refers to truthfulness and honesty. While the nurse's action can be seen as honest and caring, it does not specifically relate to the concept of veracity.

Boundary crossing refers to a situation where the nurse exceeds the established professional boundaries with the client. In this scenario, the nurse's action of obtaining a meal for the client can be seen as a minor deviation from the routine care but is not considered a significant boundary crossing.

A. "Soiled dressings should be placed in a biohazard trash receptacle B. "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub." C. "Droplet precautions require that I wear a gown and gloves when providing client care. D. "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20."

Correct Answer is A

Explanation

Placing soiled dressings in a biohazard trash receptacle is the appropriate practice for disposing of potentially infectious materials. It helps prevent the spread of microorganisms and ensures proper handling and disposal of contaminated items.

Clostridium difficile is a spore-forming bacterium that is not effectively killed by alcohol-based hand rubs. Hand hygiene for C. difficile requires the use of soap and water to thoroughly wash the hands.

Droplet precautions typically require the use of a surgical mask, not a gown and gloves. Gown and gloves are used for contact precautions.

The recommended bleach solution for blood spills is typically a 1:10 dilution, not 1:20. This concentration helps ensure effective disinfection and decontamination of the area.

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A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Correct Answer is A

Explanation

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back.

Which of the following actions should the nurse take?