A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

A toddler who has a laceration on his forehead and is crying

An adolescent female client who is belligerent and has slurred speech

A young adult with a painful sunburn of his face and arms

A middle adult male who is diaphoretic and reports epigastric pain

Answer and Explanation

The Correct Answer is D

A. A laceration on the forehead of a toddler, while needing attention, is not as urgent as symptoms suggestive of a myocardial infarction.
B. Belligerence and slurred speech in an adolescent could indicate substance use or neurological issues, but it is less immediately life-threatening than symptoms of a myocardial infarction.
C. While painful sunburn can be uncomfortable, it is not as critical as symptoms indicative of a potential heart attack.
D. Diaphoresis and epigastric pain can be symptoms of a myocardial infarction (heart attack), which is a potentially life-threatening condition requiring immediate medical attention.

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Correct Answer is C

Explanation

A. If the round, firm, moveable part is in the fundus and the long, smooth surface is on the right side, the fetal back is likely on the right side, making the fetal heart tones more audible in the right lower quadrant.
B. The right upper quadrant is less likely to have clear fetal heart tones if the fetal back is on the right side; this quadrant is typically less optimal for auscultation in this scenario.
C. Given the fetal back is on the right side, the fetal heart tones are best heard in the right lower quadrant, where the back is more prominent.
D. The left upper quadrant would not be the best place to auscultate the fetal heart tones if the fetal back is on the right side.

A. "A gain of about 25 to 35 pounds is recommended for you." B. "The recommendation for you is about 15 to 25 pounds." C. "A gain of about 1 pound per week is the best pattern for you." D. "It would be best if you gained about 11 to 20 pounds."

Correct Answer is B

Explanation

A. A weight gain of 25 to 35 pounds is recommended for women with a normal BMI (18.5–24.9). The client in this scenario has a BMI of 26.5, which places her in the overweight category.
B. The recommended weight gain for a client with a BMI of 25–29.9 (overweight) is 15 to 25 pounds. This amount of weight gain helps reduce the risk of complications such as gestational diabetes and hypertension.
C. While gaining 1 pound per week might be appropriate in the second and third trimesters, it doesn't specify the total recommended weight gain, which is more critical for a client with a BMI of 26.5.
D. A weight gain of 11 to 20 pounds is recommended for women with a BMI of 30 or higher (obese), not for those in the overweight category.

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A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

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Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is C

Explanation

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?

A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

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A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

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