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

A. Incorrect. This client is immobile but not at immediate risk from fire.
B. Incorrect. While a bedridden client wearing a hearing aid requires assistance, they are not in immediate danger like a client in traction.
C. Incorrect. A client using a wheelchair and being confused requires assistance, but the urgency is not as high as with a client in traction.
D. Correct. Oxygen is a highly combustible gas, and any spark or open flame near an oxygen source can ignite a fire. Therefore, clients receiving oxygen are at the highest risk during a fire.

A. Evaluate the client's ability to help with repositioning. B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

Correct Answer is A

Explanation

A. Correct. Evaluating the client's ability to assist with repositioning is important to ensure safe and appropriate positioning that considers the client's capabilities and comfort.
B. Incorrect. The use of assistive devices or assistance from the nurse or other personnel may be necessary to ensure safe repositioning, especially in clients with mobility limitations.
C. Incorrect. While discussing the client's preferences is important, it may not directly relate to the immediate need for repositioning after a stroke.
D. Incorrect. Raising the side rails on both sides of the bed is important for client's safety, but it doesn't address the client's need for repositioning after a stroke.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

Correct Answer is D

Explanation

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?