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Question 1 of 5

The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?

Correct Answer: A

Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.

Question 2 of 5

A new graduate nurse is assigned to a 30-year-old female requiring NG tube feeding. The preceptor reminds the graduate nurse to check placement of the NG tube before administering the feeding. The best way to do this is by

Correct Answer: B

Rationale: Aspirating gastric contents and checking pH (≤5.5 indicates gastric placement) is the most reliable bedside method to confirm NG tube placement.

Question 3 of 5

The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?

Correct Answer: C

Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.

Question 4 of 5

A client with chest pain is scheduled for a heart catheterization. Which of the following would the nurse include in the client's care plan?

Correct Answer: D

Rationale: During heart catheterization, the client may be asked to cough or breathe deeply to facilitate dye movement or assess respiratory response, a key part of preparation.

Question 5 of 5

The nurse is taking care of an elderly client with congestive heart failure. Which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.

Correct Answer: A, B, D

Rationale: Daily weights monitor fluid status, assistance with self-care reduces exertion, and post-activity vital signs assess heart workload. Sensory stimulation may increase stress.

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A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
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