For each potential provider's prescription, click to specify if the potential prescription is anticipated or unanticipated for the client.

Administer oxytocin,

Administer terbutaline.

Administer betamethasone.

Maintain bed rest with bathroom privileges.

Limit fluid intake to 3,000 mL/day.

Place client in supine position.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

1.   Administer oxytocin
Unanticipated: Oxytocin is typically used to induce labor or augment labor by stimulating uterine contractions. Since the client is already experiencing preterm labor, administering oxytocin could exacerbate contractions, leading to a more rapid progression of labor, which is not desired at 33 weeks gestation.
2.   Administer terbutaline
Anticipated: Terbutaline is a tocolytic agent used to stop preterm labor by relaxing the uterus and inhibiting contractions. Given that the client is experiencing preterm labor (with regular contractions), this medication would be used to attempt to stop labor and delay delivery, which is an appropriate action for a 33-week pregnant client with early labor signs.

3.   Administer betamethasone
Anticipated: Betamethasone is a corticosteroid that promotes lung maturity in preterm infants. At 33 weeks gestation, it is common to administer betamethasone if preterm labor is suspected, as it enhances fetal lung development and reduces the risk of respiratory distress syndrome in the newborn.
4.   Maintain bed rest with bathroom privileges
Anticipated: Bed rest is often recommended for clients with preterm labor to reduce uterine activity and promote fetal well-being. While some studies suggest limited benefits, it is still a common non- pharmacological approach to manage preterm labor and reduce the risk of premature delivery.
5.   Limit fluid intake to 3,000 mL/day
Unanticipated: There is no indication that the client is at risk for fluid overload or hyponatremia (which would require fluid restriction). In fact, hydration is often encouraged in preterm labor to prevent dehydration, which can worsen uterine contractions.
6.   Place client in supine position
Unanticipated: Supine position is not recommended during pregnancy, particularly after the first trimester, due to the risk of supine hypotensive syndrome (compression of the vena cava, leading to reduced blood flow to the uterus and fetus). In fact, lateral positioning (e.g., left side-lying) is recommended for optimal circulation.

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Correct Answer is B

Explanation

A. Offering clear liquids should typically occur 6 hours or later postoperatively; in the first few hours, the focus is on monitoring and pain management.
B. Administering analgesics on a scheduled basis ensures consistent pain control and helps prevent unnecessary discomfort.
C. Applying a warm compress is not appropriate in the early postoperative period and may risk increased bleeding.
D. Giving cromolyn nebulized solution is unrelated to appendectomy recovery and is not part of standard postoperative care.

A. Prepare the client for an MRI of the brain. B. Insert an indwelling urinary catheter for the client. C. Determine the client's Glasgow Coma Scale score. D. Administer mannitol IV bolus to the client.

Correct Answer is C

Explanation

A. Preparing the client for an MRI is not the first step; assessment of neurological status is the priority.
B. Inserting an indwelling urinary catheter is unnecessary unless indicated after further assessment.
C. Determining the Glasgow Coma Scale score is the most important initial step to assess the client's neurological status and guide further interventions.
D. Administering mannitol is appropriate for increased intracranial pressure but should only be done after assessing the client's neurological condition.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

For each potential provider's prescription, click to specify if the potential prescription is anticipated or unanticipated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?

A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?

The nurse reviews the entries in the medical record. The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session?