Nurse Logic Testing and Remediation Advanced Test | Question with 100% correct Answer | Verified

A nurse is caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the clients TPN is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations? - Shakiness and diaphoresis These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount. A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching? - "This illness will not recur because my child has now had it" It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed. A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? - Place the client in a knee-chest position Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord. Using the ABC priority setting framework, the greatest risk is the cessation of circulation to the fetus; therefore, this is the priority action the nurse should take. BUT wrapping the umbilical cord in the 0.9% sodium chloride solution is also CORRECT but not priority i guess.. A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? - Aspirin (Bayer) Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.