Exhibits

The client is at risk of developing
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and
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.

Nursing Test Bank

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Correct Answer is B

Explanation

A. "Cola soft drink." A standard 240 mL (8 oz) serving of cola contains approximately 20 to 40 mg of caffeine. While this is lower than the caffeine content in coffee or tea, it is still higher than that of hot cocoa.
B. "Hot cocoa." Hot cocoa contains the least amount of caffeine, typically around 5 mg per 240 mL (8 oz). Cocoa naturally contains small amounts of caffeine, but it is significantly lower than in coffee, tea, or soda.
C. "Brewed green tea." A 240 mL (8 oz) serving of brewed green tea contains approximately 30 to 50 mg of caffeine. While green tea has less caffeine than coffee, it still has more than hot cocoa.
D. "Instant coffee." Instant coffee has one of the highest caffeine contents per 240 mL (8 oz), ranging from 60 to 80 mg. This makes it a less suitable choice for someone trying to reduce caffeine intake.

A. Open curtains between clients in semiprivate rooms. B. Wear shoes with rubber soles. C. Conduct change-of-shift report near the clients' rooms. D. Turn on overhead lights briefly when checking IV lines.

Correct Answer is B

Explanation

A. Open curtains between clients in semiprivate rooms. Keeping curtains closed between clients helps reduce noise, light, and distractions, promoting a more restful environment. Open curtains can increase disturbances and compromise privacy.
B. Wear shoes with rubber soles. Rubber-soled shoes help minimize noise from footsteps, reducing disruptions to clients' sleep. Hard-soled shoes can create unnecessary noise, contributing to environmental stressors in an acute care setting.
C. Conduct change-of-shift report near the clients' rooms. Shift reports should be conducted away from client rooms to limit noise exposure. Conversations near sleeping clients can be disruptive, reducing sleep quality and contributing to stress.
D. Turn on overhead lights briefly when checking IV lines. Bright overhead lighting can disturb clients' sleep. Using a flashlight or dim bedside lighting is a better approach to minimize disruptions while ensuring safe IV checks.

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Exhibits The client is at risk of developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine?

Correct Answer is B

Explanation

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information?

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is unfamiliar with a medication they are preparing to administer to a client. Prior to administering the medication, the nurse should refer to which of the following resources?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Exhibits Select the 2 actions the nurse should prepare to take for the client.

A nurse is collecting data from a client who is receiving continuous IV fluids in their left forearm. Which of the following findings should the nurse identify as an indication of infiltration at the IV infusion site? (Select all that apply.)

A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

Exhibits

The client is at risk of developing
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and
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