PN Comprehensive Online Practice 2024 A
Questions and Correct Answer
A nurse is assisting in the care of a client who is 1 hr postpartum.
Exhibit 1
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the
umbilicus.Oxytocin 20 units being administered via continuous IV infusion
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin
cool and clammy. Provider notified.
Exhibit 2
Vital Signs
1200:
Temperature 37.5° C (99.5° F)Heart rate 92/minRespiratory
o :### Select the 6 actions the nurse should take.
Weigh the perineal pads.
Insert an indwelling urinary catheter.
Administer methylergonovine.
Provide emotional support.
Administer oxygen at 12 L/min via nonrebreather face mask.
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Firmly massage the uterine fundus.
When taking action for the client, the nurse should firmly massage the uterine fundus, administer
methylergonovine, weigh the perineal pads, provide emotional support, insert an indwelling urinary
catheter, and administer oxygen at 12 L/min via nonrebreather face mask. The nurse should
identify that the client is experiencing a postpartum hemorrhage, which requires immediate
intervention to prevent hemorrhagic shock.
A nurse is collecting data from a client who is scheduled for surgery.
Exhibit 1
Vital Signs
0630:
Temperature 36.9° C (98.5° F)Heart rate 74/minRespiratory rate 20/minBlood pressure 122/76
mmHgOxygen saturation 96% on room air
0730:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 20/minBlood pressure 128/78
mmHgOxygen saturation 95% on room air
Exhibit 2
Nurses' Notes
0630:
Client reports restlessness and inability to sleep more than 3 to 4 hr per night for the last week. Cli
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o :### Click to highlight the data collection findings that the nurse should report to
the provider prior to the procedure. To deselect a finding, click on the finding
again.
Hemoglobin level
Allergy
Family history
When collecting data from the client and analyzing cues, the nurse should determine the client's
hemoglobin level, latex allergy, and family history of malignant hyperthermia should be reported to
the provider. When the client's hemoglobin level is below the expected range, the client might
require blood products during the intraoperative phase. The client's allergy to avocados and
bananas can indicate an allergy to latex products and should be reported to the provider. The
surgical team will need to remove all latex products from the operating room. During the
intraoperative phase, the nurses must be diligent in monitoring the client's vital signs and
laboratory values, especially in a client who has a family history of malignant hyperthermia.
A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using
eating utensils. The nurse should identify the need for a referral to which of the following
interprofessional team members?
o :### Occupational therapist
The nurse should identify the need for a referral to an occupational therapist to teach the client
how to use special eating utensils.
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A nurse is reviewing the electronic health records of four clients. Which of the following client
conditions should the nurse recognize as reportable to a regulatory agency?
o :### A client who is newly diagnosed with tuberculosis
The nurse should identify that certain communicable diseases, such as tuberculosis, require
notification of the local and state health departments.
A nurse is caring for a client who is being discharged home following a cerebrovascular accident.
Which of the following documents should the nurse plan to include with the discharge report?
o :### List of potential complications to report
Discharge instructions are defined as any form of documentation provided to the client, upon
discharge to home, which facilitates safe and appropriate continuity of care. The nurse should plan
to include a list of potential complications that should be reported to the provider in the client's
discharge instructions.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which
of the following statements by the parent indicates an understanding of the teaching?
o :### "I should offer my child yogurt that has a probiotic as a snack."
Children who have lactose intolerance should be offered dairy products that have a probiotic, such
as lactobacillus. The probiotic promotes tolerance of lactose in the colon.
A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus. Which of the following
client statements indicates an understanding of the teaching?
Master01: DO NOT COPY AND PASTE!! August 21, 2024 Latest Update
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