A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?

Client report of burning with urination

Saturation of perineal pad in 15 min

Boggy fundus 3 fingerbreadths above the umbilicus

Client report of uterine cramping

Answer and Explanation

The Correct Answer is D

Oxytocin is a medication commonly used to induce or enhance uterine contractions. Therefore, it is expected that the client may experience uterine cramping after receiving oxytocin. The medication helps to contract the uterus, which can aid in controlling excessive vaginal bleeding.

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Correct Answer is D

Explanation

Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.

The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.

During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.

The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.

A. Evaluate the need for the client to remain in mitten restraints. B. Assist the client with range-of-motion exercises of the hands. C. Instruct the client's family about the purpose of mitten restraints. D. Determine the circulation status of the affected extremities every 2 hr

Correct Answer is B

Explanation

Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.

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A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is B

Explanation

A nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings as the priority to report to the provider?

A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who has hypothyroidism and a new prescription for levothyroxine. The nurse should instruct the client to notify the provider of which of the following manifestations of thyrotoxicosis?

A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?