The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

Start an IV bolus of lactated Ringer's solution.

Stay with the client for the first 15 min of the transfusion.

Obtain the first unit of packed RBCs from the blood bank.

Document the blood product transfusion in the client's medical record.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

A. Start an IV bolus of lactated Ringer's solution: Not Indicated

- The client's medical record does not indicate a need for fluid resuscitation or immediate volume replacement.

B. Stay with the client for the first 15 min of the transfusion: Not Indicated

- There is no mention of a blood transfusion in the provided information. Therefore, staying with the client during a transfusion is not relevant.

C. Obtain the first unit of packed RBCs from the blood bank: Not Indicated

- There is no indication of a need for a blood transfusion in the client's assessment findings.

D. Document the blood product transfusion in the client's medical record: Not Indicated
- Since there is no indication of a blood transfusion, documenting a transfusion is not relevant.

E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: Not Indicated
- While it's important to monitor and maintain the client's blood pressure, the provided information does not suggest that the client's blood pressure is significantly low (90/60 mm Hg) or that they are receiving any infusions that need titration for blood pressure management.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Incorrect. Postural drainage is usually performed multiple times a day, usually three to four times, to effectively mobilize respiratory secretions.
B. Incorrect. Percussions are typically performed using cupped hands to create vibrations. Holding the hand flat would not produce the desired effect.
C. Bronchodilator should be administered PRIOR to procedure if prescribed
D. Postural drainage should be performed before meals or at least 1-2 hours after meals to prevent vomiting or aspiration.

A. "I will get oxytocin during this test.” B. "During this test, I must not eat or drink anything.” C. "This test will tell me if my baby has a genetic problem.” D. "During this test, I will push a button if my baby moves.”

Correct Answer is D

Explanation

Choice A rationale:

Oxytocin is not typically administered during a nonstress test. Oxytocin is a hormone that induces or augments labor contractions; it is not used in nonstress testing, which monitors fetal heart rate and movement. The administration of oxytocin during nonstress testing would not be appropriate or necessary.

Choice B rationale:

Fasting is not required for a nonstress test. Nonstress testing involves attaching electronic fetal monitors to the mother's abdomen to measure the baby's heart rate and movement. It does not require the patient to abstain from eating or drinking. Imposing unnecessary restrictions on the client's diet could cause discomfort and anxiety, which is not conducive to an accurate assessment.

Choice C rationale:

Nonstress testing is used to evaluate the baby's heart rate response to its own movements. It does not diagnose genetic problems. Genetic testing, such as amniocentesis or chorionic villus sampling, is a different type of test used to detect genetic abnormalities in the fetus. Therefore, this statement does not reflect an understanding of the purpose of nonstress testing.

Choice D rationale:

This is the correct answer. Nonstress testing involves monitoring the baby's heart rate and movement. During the test, the mother pushes a button when she feels the baby move. This allows the healthcare provider to correlate fetal movements with changes in the baby's heart rate. An understanding of this process indicates that the client comprehends the purpose and procedure of the nonstress test.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching a client who is pregnant about nonstress testing.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?

A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

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

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?

Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.