The nurse continues to care for the client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Urine culture

Vaginal culture

Ibuprofen 600 mg every 6 hr for mild to moderate pain

Obtain provider prescription for phenazopyridine

Obtain provider prescription for antibiotics

Answer and Explanation

Correct Answer : A,B,D,E

A. Urine culture: The client has fever (38.4°C), dysuria, leukocyte esterase, and WBC casts in the urine, suggesting a urinary tract infection (UTI) or pyelonephritis. A urine culture is necessary to identify the causative organism and guide antibiotic therapy.
B. Vaginal culture: The client has preterm contractions and a history of preterm birth. Infections (e.g., bacterial vaginosis, Group B Streptococcus, sexually transmitted infections) can trigger preterm labor. A vaginal culture can help determine if an infection is contributing to labor symptoms.
C. Ibuprofen 600 mg every 6 hr for mild to moderate pain: NSAIDs (e.g., ibuprofen) are contraindicated in pregnancy after 30 weeks gestation because they can cause premature closure of the ductus arteriosus, leading to fetal circulation issues and increase the risk of oligohydramnios (low amniotic fluid levels) by reducing fetal kidney function. Instead, acetaminophen (Tylenol) is preferred for pain relief in pregnant clients.
D. Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic used to relieve dysuria and bladder discomfort. This medication does not treat the infection but provides symptomatic relief while waiting for antibiotics to take effect.
E. Obtain provider prescription for antibiotics: The presence of WBC casts, fever, and positive leukocyte esterase suggests a UTI, possibly progressing to pyelonephritis. Prompt antibiotic therapy is critical to prevent complications such as preterm labor, maternal sepsis, or fetal distress.

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Correct Answer is ["A","B","E"]

Explanation

A. Have a second nurse confirm the information on the blood label: Two nurses must verify the blood product (blood type, Rh factor, client identification) before administration to prevent transfusion reactions due to mismatched blood.
B. Witness the client signing a consent for transfusion: Blood transfusion requires informed consent because of risks such as hemolytic reactions, febrile reactions, and infections. The nurse can witness the signature, but the provider must explain the risks, benefits, and alternatives.
C. Explain to the client that transfusion reactions are not serious: This is false and misleading. Blood transfusion reactions can range from mild (fever, chills) to life-threatening (anaphylaxis, hemolysis, sepsis). The nurse should instead educate the client on signs of a transfusion reaction (fever, chills, back pain, difficulty breathing, hypotension) and instruct them to report any symptoms immediately.
D. Flush the transfusion tubing with dextrose 5% in water: Dextrose (D5W) should never be used to flush blood transfusion tubing because it can cause hemolysis of red blood cells. Instead, 0.9% sodium chloride (normal saline) is the only compatible fluid for flushing blood transfusion tubing.
E. Insert a large-bore IV catheter: A large-bore (18- to 20-gauge) IV catheter is required for blood transfusion to ensure adequate flow and prevent clotting. Smaller catheters (22- to 24-gauge) are inadequate for rapid blood transfusions.

A. Smacking lips B. Serpentine limb movement C. Shuffling gait D. Nonreactive pupils

Correct Answer is C

Explanation

A. Smacking lips is associated with tardive dyskinesia, not pseudoparkinsonism.
B. Serpentine (writhing) limb movement is characteristic of chorea or tardive dyskinesia, not pseudoparkinsonism.
C. Pseudoparkinsonism is an extrapyramidal side effect (EPS) of antipsychotics like haloperidol. It mimics Parkinson's disease and includes shuffling gait, muscle rigidity, tremors, and bradykinesia.
D. Nonreactive pupils are not a symptom of pseudoparkinsonism.

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Assessment	Findings
Nurses' Notes	Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. FHR baseline 138, minimal variability. No further reports of burning with urination.
Laboratory Results	WBC 12, 000/mm3 (5000 to 10000/mm3) Platelet count 188000/mm3 (150000 to 400000/mm3)
Vital Signs	Temperature 37.1°C (98.7°F) Blood pressure 120/78 mmHg

The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?

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?

The nurse continues to care for the client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.