A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome
does the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg
Give this one a try later!
D, E
,A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that
she felt a large gush of fluid from her vagina on the way to the hospital. The nurse
detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that
the umbilical cord is protruding from the vagina. Which actions should the nurse
perform? Select all that apply.
Placing the woman in knee-chest position
Administering oxygen at 2 to 4 L/min by nasal cannula
Administering terbutaline to stop contractions
With two gloved fingers, exerting upward pressure, into the vagina, on the presenting
part
Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline
solution
Give this one a try later!
A, C, D
Oxygen should be administered at 8-10 L/min via face mask
A nurse is caring for a client with increased intracranial pressure. In which position should
the nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
Give this one a try later!
, D
Proper positioning promotes venous drainage from the cranium to minimize
ICP.
A client has recently been diagnosed with deep vein thrombosis of the right leg. Which
of the following interventions of the nurse immediately implement?
a. Elevating the foot of the bed 6 inches
b. Placing ice packs on and under the right leg
c. Documenting the need for hourly calf measurements
d. Performing the need for hourly calf measurements
Give this one a try later!
A
DVT treatment includes bed rest, leg elevation, and application of warm, moist
heat. Elevation decreases the venous pressure with relieves edema and pain.
ROM cause cause the thrombus to mobilize to the lungs causing PEs.
A nurse developing a plan of care for a client with a spinal cord injury includes measures
to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse
incorporate into the plan to prevent this complication?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories
Give this one a try later!
does the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg
Give this one a try later!
D, E
,A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that
she felt a large gush of fluid from her vagina on the way to the hospital. The nurse
detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that
the umbilical cord is protruding from the vagina. Which actions should the nurse
perform? Select all that apply.
Placing the woman in knee-chest position
Administering oxygen at 2 to 4 L/min by nasal cannula
Administering terbutaline to stop contractions
With two gloved fingers, exerting upward pressure, into the vagina, on the presenting
part
Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline
solution
Give this one a try later!
A, C, D
Oxygen should be administered at 8-10 L/min via face mask
A nurse is caring for a client with increased intracranial pressure. In which position should
the nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
Give this one a try later!
, D
Proper positioning promotes venous drainage from the cranium to minimize
ICP.
A client has recently been diagnosed with deep vein thrombosis of the right leg. Which
of the following interventions of the nurse immediately implement?
a. Elevating the foot of the bed 6 inches
b. Placing ice packs on and under the right leg
c. Documenting the need for hourly calf measurements
d. Performing the need for hourly calf measurements
Give this one a try later!
A
DVT treatment includes bed rest, leg elevation, and application of warm, moist
heat. Elevation decreases the venous pressure with relieves edema and pain.
ROM cause cause the thrombus to mobilize to the lungs causing PEs.
A nurse developing a plan of care for a client with a spinal cord injury includes measures
to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse
incorporate into the plan to prevent this complication?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories
Give this one a try later!
