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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Providing oral hygiene care is important but not the first priority after a client has vomited
B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.
C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.
D. Correct. Evaluating the functioning of the suction device is important as it helps to prevent aspiration of contents.
Correct Answer is A
Explanation
A. Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.
B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.
C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.
D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.
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