The nurse continues to care for the client.

Nurses' Notes Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.
CBC and urinalysis collected and sent to lab. Day 1,0930:
Peripheral IV initiated. Provider prescriptions received and implemented. Day 1, 1000:
Client voided and reports pain and dicomfort upon urination. Client states, "I've noticed burning wife I urinate for the past 2 days."

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

Urine culture

Ibuprofen 600 mg every 6 hr for mild to moderate pain

Obtain provider prescription for phenazopyridine

Vaginal culture

Obtain provider prescription for antibiotics

Answer and Explanation

Correct Answer : A,C,E

A.   Urine culture: This will help identify the presence of any urinary tract infection (UTI) causing discomfort and burning during urination.
B.   Ibuprofen 600 mg every 6 hr for mild to moderate pain: While ibuprofen can help with pain relief, it does not address the potential underlying urinary tract infection, so it's important to address the infection first.
C.   Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can provide relief from the pain and discomfort associated with UTIs.
D.   Vaginal culture: The client's symptoms are related to discomfort and burning upon urination, suggesting a urinary tract issue rather than a vaginal issue. Therefore, a vaginal culture may not be relevant in this context.
E.   Obtain provider prescription for antibiotics: If a urinary tract infection is suspected based on the client's symptoms and urine culture results, antibiotics may be needed to treat the infection.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

As explained, holding the bottle directly over the sterile field can result in contamination. It's crucial to pour the solution from above or to the side of the sterile field, making sure the bottle doesn't touch the field or anything in the field. This minimizes the risk of contaminating the sterile setup.

If solution is spilled on the sterile field, that area is contaminated, and you cannot make it sterile again by covering it with gauze. The correct approach would be to discard the contaminated items and set up a new sterile field.

While it's important not to touch the label side of the bottle, this option doesn't address the action of placing the cap. The most important part of pouring a sterile solution is ensuring the cap stays sterile, which is what option D addresses.

When performing a sterile procedure, after removing the cap from a sterile bottle, the cap should be placed sterile-side up on a clean surface or a sterile field. This is because the sterile side of the cap should not touch any non-sterile surfaces, and placing it sterile-side up ensures it stays sterile.

A. Temporarily discontinue the infusion. B. Give 500 mL of lactated Ringer's solution. C. Administer dextrose 10% in water. D. Slow the TPN infusion rate.

Correct Answer is C

Explanation

A. Incorrect. Temporarily discontinuing the TPN infusion may result in an abrupt decrease in the client's glucose intake, which could lead to hypoglycemia.
B. Incorrect. Giving lactated Ringer's solution would not address the client's TPN needs and may also affect electrolyte balance.
C. Administering dextrose 10% in water wouldprovide the required glucosed as the next bag is awaited
D. Slowing the TPN infusion rate can help stretch the remaining volume until a new bag becomes available. However, it does not adress the body's glucose requirements.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which of the following actions should the nurse take?

Correct Answer is C

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?

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?

A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?

A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?

A nurse is caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown due to dropdown.

A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?