The nurse is assisting in the care of the client who is at 30 weeks of gestation. Nurses' Notes
1200:
Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.
Encouraged client to cough and take deep breaths regularly.
Assisted with insertion of 18-gauge IV and initiation of IV fluid.
Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict 180.
FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.
1400:
Client is lethargic. Heart rate regular, respirations shallow DTR 1+ bilaterally.
Urine output 20 mL in the last hour
1405:
Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.
1800:
Client is alert and responsive. Heart rate regular respirations even and unlabored. DTR 2- bilaterally
Oxygen saturation (SaO) 95% on 2 L nasal cannula Respiratory rate 18/min
Select the findings that indicate the client's condition has improved.
Urine pupus 40 mL in the last hour
Temperature 38.3" C(101 F)
Blood pressure 146/96 mm Hg
Urine output 40 mL
Deep tendon reflexes 2+ bilaterally
Heart rate 58/min
Correct Answer : D,F
These findings suggest that the client's urine output has increased, the deep tendon reflexes are within normal limits, and the heart rate has improved and is closer to the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.
They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.
The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.
The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.
The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.
The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.
Correct Answer is D
Explanation
The correct answer is D. Roasted salmon. A kosher diet is based on Jewish dietary laws that prohibit certain foods and combinations of foods. Some of these rules include avoiding pork, and shellfish, and mixing meat and dairy products. Therefore, shrimp salad, pulled pork sandwich, and clam chowder are all non-kosher menu items that should be avoided by a
client who follows a kosher diet. Roasted salmon is a kosher menu item that can be included on the tray, as long as it is not served with any dairy products or non-kosher ingredients.
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