After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?

Place the client in the Trendelenburg position.

Remove the client's legs from the stirrups.

Instruct the client to take deep breaths.

Place a wedge under the client's hip.

Answer and Explanation

The Correct Answer is D

A. Place the client in the Trendelenburg position: While this position may increase venous return, it does not address the underlying cause in a pregnant client, which is usually aortocaval compression by the uterus. Simply tilting the table may be less effective than proper lateral displacement.

B. Remove the client's legs from the stirrups: Removing the legs may relieve some discomfort but does not correct the maternal hypotension caused by pressure on the inferior vena cava. Additional interventions are needed to improve circulation.

C. Instruct the client to take deep breaths: Deep breathing may help with anxiety or mild shortness of breath but does not resolve the hemodynamic compromise caused by supine hypotensive syndrome.

D. Place a wedge under the client's hip: Placing a wedge under the right or left hip tilts the uterus off the inferior vena cava, improving venous return, cardiac output, and blood pressure. This is the priority action to relieve dizziness, pallor, and diaphoresis in a pregnant client at 26 weeks’ gestation.

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Correct Answer is C

Explanation

A. Encourage positive self accolades for dietary adherence: While supportive reinforcement is helpful for long-term behavior change, it does not address the immediate problem of vomiting and inability to tolerate food and liquids.

B. Determine if the client is over-hydrating to feel satiated: Assessing hydration habits may be part of long-term dietary counseling, but it is not the priority intervention when the client is acutely vomiting and unable to tolerate intake.

C. Maintain the client on an NPO status: Keeping the client NPO prevents further vomiting, reduces the risk of aspiration, and allows the gastrointestinal tract to rest. This is the immediate priority intervention in managing post-bariatric surgery complications such as obstruction or delayed gastric emptying.

D. Administer daily vitamin supplements: Vitamins are important for nutritional maintenance after bariatric surgery, but administering them orally is not appropriate when the client cannot tolerate food or liquids. Nutritional support should be deferred until tolerance improves.

A. Reapply a sterile non-adhesive dressing. B. Administer prescribed antibiotics. C. Request a nutrition consult. D. Limit visitors to immediate family only.

Correct Answer is B

Explanation

A. Reapply a sterile non-adhesive dressing: While maintaining a clean dressing is important to prevent further contamination, it does not address the underlying MRSA infection causing the wound to worsen.

B. Administer prescribed antibiotics: Prompt administration of antibiotics is the priority because the wound is infected with MRSA and is enlarging, indicating active infection that requires systemic treatment to prevent sepsis and promote healing.

C. Request a nutrition consult: Adequate nutrition supports wound healing, but it is a secondary intervention and does not immediately treat the infection or stop its progression.

D. Limit visitors to immediate family only: Limiting visitors may reduce infection risk to others, but it does not directly treat the MRSA infection or address the acute worsening of the wound.

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After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Correct Answer is B

Explanation

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