A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

"Assist her to breathe in deeply at the beginning of each contraction."

"Apply steady pressure with this tennis ball to her sacral area."

"Gently stroke her abdomen during contractions."

"Help her to focus on an object in the room."

Answer and Explanation

The Correct Answer is C

The correct answer is C. Effleurage is a type of massage that involves gently stroking or rubbing the abdomen during contractions to provide comfort and distraction. It can also stimulate endorphin release and reduce pain perception. Breathing deeply at the beginning of each contraction is a relaxation technique, not effleurage. Applying pressure to the sacral area with a tennis ball is a counterpressure technique, not effleurage. Focusing on an object in the room is a focal point technique, not effleurage.

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Correct Answer is D

Explanation

Choice A reason:

"I should gargle with an alcohol-based mouthwash to kill germs”. This statement is not appropriate. Using an alcohol-based mouthwash is not recommended for a client with stomatitis. Alcohol can be irritating to the already inflamed mucous membranes and may worsen the condition. Instead, the client should use a mild, non-alcohol-based mouthwash or rinse as prescribed by the healthcare provider.

Choice B option

"I should limit my intake of dairy products to prevent nausea." This statement is not appropriate. While some clients may experience nausea during radiation therapy, limiting dairy products is not specifically related to stomatitis management. The client should follow any dietary recommendations provided by the healthcare provider or a registered dietitian to address nausea or other dietary concerns.

Choice C option

"I should moisten my lips with lemon-glycerine swabs." This is incorrect because lemon-glycerine swabs can be drying and irritating to the oral mucosa, which may exacerbate stomatitis symptoms. Instead, using a gentle, non-irritating lip balm or petroleum jelly is preferred.

Choice D option

"I should use a soft-bristle toothbrush to clean my teeth after meals. “This response indicates an understanding of the teaching because a soft-bristle toothbrush is gentle on the gums and oral tissues, which is important for a client with stomatitis, as it helps to minimize irritation and injury.

A. Document the infiltration. B. Stop the infusion. C. Elevate the arm. D. Apply a warm compress.

Correct Answer is B

Explanation

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

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A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to assess the newborn's pain?

A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?

A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.Which of the following statements by the parent indicates an understanding of the teaching?