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 A

Explanation

A. This statement is appropriate because it respects the client’s autonomy and acknowledges that the client has the right to withdraw consent at any time.
B. Telling the client their doctor wouldn't have ordered the treatment unless it was necessary can be dismissive of the client’s concerns and feelings.
C. While it’s important to acknowledge that nervousness or anxiety is a normal response, this statement does not directly address the client’s concern about not proceeding with the treatment.
D. Telling the client that most people feel better after the procedure may sound dismissive of the
client’s hesitation and doesn’t address their concerns directly.

A. Offer small amounts of clear liquids 6 hr following surgery. B. Administer analgesics on a scheduled basis for the first 24 hr. C. Apply a warm compress to the operative site once daily. D. Give cromolyn nebulized solution every 8 hr.

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.

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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 caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?

Correct Answer is A

Explanation

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 is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?

A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?