PRACTICE 2025 B | 2 DIFFERENT
VERSIONS | ALL QUESTIONS AND
CORRECT ANSWERS | ALREADY
GRADED A+ | LATEST VERSIONS
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 - 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.
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 -
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? - 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.
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? - 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? - 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? - "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? - "I should check my blood sugar if my
appetite is decreased."
The nurse should instruct the client to monitor blood glucose levels closely. Change in appetite can be
an early sign of hyperglycemia and inadequate intake may cause blood glucose to drop.
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings
should the nurse expect? - Difficulty concentrating
In clients who have iron deficiency anemia, body cells do not receive the required oxygen because there
is less hemoglobin for binding. The nurse should recognize that impaired oxygenation of brain tissue can
lead to dizziness and difficulty concentrating.
A nurse is caring for a client who is immunocompromised. Which of the following immunizations is
contraindicated? - Measles, mumps, and rubella (MMR)
The MMR vaccine consists of a live virus and is contraindicated for a client who is immunocompromised.
A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following
methods should the nurse use when communicating with the client? - Provide a picture board.