During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?

Acceleration.

Nonreactive pattern.

Fetal movement.

Positive tracing.

Answer and Explanation

The Correct Answer is A

A. Acceleration refers to a temporary increase in the fetal heart rate of at least 15 beats per minute above the baseline for at least 10 seconds. The observation of the fetal heart rate increasing 15 beats above baseline twice during the test indicates that accelerations are present, which is a reassuring sign of fetal well-being.
B. A nonreactive pattern would indicate that the test did not meet the criteria for accelerations or fetal heart rate reactivity, which is not the case here as the fetal heart rate did exhibit accelerations.
C. Fetal movement could contribute to accelerations but is not the term used to describe the findings of the test itself. The specific observation made was an increase in fetal heart rate, which is classified as an acceleration.
D. A positive tracing indicates that the nonstress test met criteria for fetal well-being, typically with at least two accelerations, but the correct term for the specific observation here is acceleration rather than describing the overall result.

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Correct Answer is A

Explanation

A. A preschooler who had an emergency appendectomy should be checked first. Children are at higher risk for complications due to their size and the stress of emergency surgery, so close monitoring is essential.
B. An adult with osteomyelitis post-surgery is important to monitor but is generally at lower immediate risk compared to a young child following emergency surgery.
C. A post-menopausal client with breast cancer who had a lumpectomy is also a priority, but the immediate postoperative period for a child in emergency surgery takes precedence.
D. An adolescent with type 1 diabetes who had cholecystectomy requires careful monitoring, but the child’s higher risk in the immediate postoperative phase makes them the priority.

A. Gloves B. N95 Mask C. Gown D. Surgical Mask E. Goggles

Correct Answer is ["A","C","D"]

Explanation

A. Gloves
Gloves are essential when entering the room because MRSA (Methicillin-resistant Staphylococcus aureus) is a pathogen that can be transmitted through direct contact with contaminated surfaces or secretions. Gloves protect both the client and the PN from the spread of the infection and should be worn when touching the patient or surfaces/items in the room.
B. N95 Mask
An N95 mask is not required for MRSA infections unless there are concerns about airborne transmission, which is not typical for MRSA. MRSA transmission is primarily through direct or indirect contact rather than airborne routes, so an N95 mask is not necessary in this scenario.
C. Gown
A gown is required when there is a risk of contamination from the environment or the patient, especially with MRSA infections. It helps to protect the PN’s clothing and skin from coming into contact with any infectious materials from the surgical site.
D. Surgical Mask
A surgical mask is appropriate for MRSA to protect against droplets and to prevent the spread of infection. It is particularly useful if there is a risk of droplets from the patient or if the PN is performing procedures that might generate droplets.
E. Goggles
Goggles are not required for MRSA unless there is a specific risk of splash or spray that could potentially expose the PN’s eyes to infectious materials. In the context of a surgical site infection, goggles are not a standard part of the PPE unless additional procedures are being performed that involve splashes

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During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is planning evening shift rounds for a group of postoperative clients who all had surgery earlier that day. Which client should the PN check first?

Correct Answer is A

Explanation

Exhibits The practical nurse (PN) has received report and is preparing to enter the room to assess the client. What personal protective equipment (PPE) should the PN don before entering the room? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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