Question

A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea which of actions should the nurse take?

Answer 1

Correct Answers:

Position the Client on her Side.

Rationale :

🌟 At 36 weeks gestation, the gravid uterus can compress the inferior vena cava when the client lies flat, reducing venous return and causing symptoms like nausea, dizziness, and hypotension.

🌟 This is known as supine hypotensive syndrome, and it impairs both maternal circulation and fetal oxygenation.

🌟 Turning the client to the left lateral position relieves the compression, restores cardiac output, and alleviates nausea by improving uteroplacental perfusion.

🌟 This is the safest and most immediate action to protect both maternal and fetal well-being.

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Answer 2

Correct Answers:

Anticipate prescription glucagon.
Check the client blood glucose level

Rationale :

✾ The client is showing clinical signs of hypoglycemia (disorientation, tremors, cool skin) despite a previously elevated glucose reading. Insulin effects can peak after administration, causing rapid glucose drops.

✾ The first action is to check the current blood glucose level to confirm hypoglycemia, since symptoms strongly suggest it.

✾ The second action is to anticipate a prescription for glucagon, which is used when the client is symptomatic and unable to consume oral glucose or if they become unconscious.

✾ These are both priority interventions based on the symptoms, timing of insulin administration, and glucose fluctuation risk.

✾ Other options (orthostatic BP check, cooling blanket, IV insulin) are not indicated or may worsen the situation.

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Answer 3

Correct Answers:

Diphenhydramine.

Rationale :

✪ Urticaria following antibiotic administration indicates a mild to moderate allergic reaction, often mediated by histamine release.

✪ Diphenhydramine, an H1 histamine receptor blocker, is the first-line treatment to reduce itching, swelling, and redness.

✪ It stabilizes the allergic response and may prevent progression to anaphylaxis if given early.

✪ It is essential for managing skin manifestations of hypersensitivity reactions, particularly with medications.

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Answer 4

Correct Answers:

Using an electronic messaging system to remind clients when to take medications’

Rationale :

✬ Tertiary prevention involves minimizing complications and improving treatment compliance in those already diagnosed with a chronic disease like HIV.

✬ Medication reminders via digital systems support treatment adherence and help prevent disease progression and resistance.

✬ This action improves long-term outcomes and reduces hospitalization risks.

✬ It is a client-specific intervention aimed at enhancing management of the existing condition.

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Answer 5

Correct Answers:

You can delegate this task if the AP has been trained to use our scales."

Rationale :

⭐ Weighing clients is a non-invasive, routine task appropriate to delegate if the assistive personnel (AP) is trained and competent in using the equipment.

⭐ Delegation is appropriate when the task does not involve initial assessment, clinical judgment, or evaluation.

⭐ The nurse retains responsibility for interpreting the weight data as part of the nursing process.

⭐ Ensuring proper training maintains safety and accuracy in care delivery.

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Answer 6

Correct Answers

Blank 1 Correct Option: Compartment syndrome.

Rationale :

✯ The client has decreased perfusion (cool foot, delayed cap refill, numbness, no pulses), indicating neurovascular compromise.

✯ These are hallmark signs of compartment syndrome, a surgical emergency caused by increased pressure in a closed muscle compartment.

✯ Early diagnosis is critical to prevent ischemia and permanent damage to nerves and muscles.

✯ Prompt action such as reporting to the provider and preparing for fasciotomy is essential.

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Answer 7

Correct Answers:

First-degree atrioventricular block.

Rationale :

✭ A PR interval > 0.20 seconds (in this case, 0.35 seconds) on the ECG indicates a first-degree AV block.

✭ It reflects a delay in conduction from the atria to the ventricles, but each impulse still reaches the ventricles.

✭ Often asymptomatic, this rhythm is commonly associated with aging, medications, or ischemic heart disease.

✭ It requires monitoring but usually does not require immediate intervention unless symptomatic or progressive.

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Answer 8

Correct Answers:

Provide a diet high in protein and calories.

Rationale :

✰ Children with cystic fibrosis have increased metabolic demands and nutrient malabsorption, especially of fats and proteins.

✰ A high-calorie, high-protein diet helps support growth and prevent malnutrition, which is a common complication.

✰ Pancreatic enzyme replacement is also important, but diet is foundational to maintaining weight and energy.

✰ This recommendation supports overall health, lung function, and immune response in these clients.

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Answer 9

Correct Answers:

Critical pathways should reduce health care costs.

Rationale :

✮ Critical pathways are structured multidisciplinary care plans that outline best practices and expected outcomes over a specific time frame.

✮ They aim to standardize care, reduce variation, and improve efficiency and quality, ultimately lowering healthcare costs.

✮ Variances can be managed but do not discontinue the pathway unless clinically necessary.

✮ They are created using evidence-based data, not solely from nursing notes.

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Answer 10

Correct Answers:

Rise slowly when getting out of bed

Rationale :

✪ Furosemide is a loop diuretic that can cause volume depletion and orthostatic hypotension, increasing fall risk.

✪ Educating clients to rise slowly helps prevent dizziness or syncope.

✪ Clients also need to be taught about potential hypokalemia, but this specific action targets the most immediate safety risk.

✪ Monitoring for dehydration and electrolyte imbalances is also essential.

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QLexNursing

1 :
A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea which of actions should the nurse take?

2 :
A nurse caring for a client on the medical surgical unit.

Answer Options

3 :
A nurse is caring for a client who has urticaria following administration of an antibiotic. Which of the following medication should the nurse prepare to administer

4 :
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic- Which of the following tasks should the nurse identify as tertiary prevention

5 :
A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistance personnel (AP). Which of the following responses should the nurse make?

6 :
A nurse is caring for a client in an orthopedic unit.

Correct Answers

7 :
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R interval of 0 35 seconds. Which of the following dysrhythmias is the client displaying?

8 :
A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which ofthe following the instructions should the plan to include;

9 :
A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse to include;

10 :
A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide Which of the following the nurse make?

QLexNursing

1 : A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea which of actions should the nurse take?

2 : A nurse caring for a client on the medical surgical unit.

Answer Options

3 : A nurse is caring for a client who has urticaria following administration of an antibiotic. Which of the following medication should the nurse prepare to administer

4 : A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic- Which of the following tasks should the nurse identify as tertiary prevention

5 : A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistance personnel (AP). Which of the following responses should the nurse make?

6 : A nurse is caring for a client in an orthopedic unit.

Correct Answers

7 : A nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R interval of 0 35 seconds. Which of the following dysrhythmias is the client displaying?

8 : A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which ofthe following the instructions should the plan to include;

9 : A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse to include;

10 : A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide Which of the following the nurse make?

1 :
A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea which of actions should the nurse take?

2 :
A nurse caring for a client on the medical surgical unit.

3 :
A nurse is caring for a client who has urticaria following administration of an antibiotic. Which of the following medication should the nurse prepare to administer

4 :
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic- Which of the following tasks should the nurse identify as tertiary prevention

5 :
A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistance personnel (AP). Which of the following responses should the nurse make?

6 :
A nurse is caring for a client in an orthopedic unit.

7 :
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R interval of 0 35 seconds. Which of the following dysrhythmias is the client displaying?

8 :
A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which ofthe following the instructions should the plan to include;

9 :
A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse to include;

10 :
A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide Which of the following the nurse make?