NUR 2210 HESI EXIT

A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? A. Allow client to use the bedpan B. Explain the fet ...

A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? A. Allow client to use the bedpan B. Explain the fetal head is descending C. Perform a sterile vaginal exam D. Assist the client to the bathroom C. Perform a sterile vaginal exam 2 The nurse assesses a 78 y.o. male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit? A. Dyspnea, cough, fatigue B. Hepatomegaly and distended neck veins C. Pain over pericardium and friction rub D. Narrowing pulse pressure and distant heart sounds A. Dyspnea, cough, fatigue 3 A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22 y.o. son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior anymore since all she does is care for their son. What intervention should the nurse implement? A. Teach the client to problem solve for herself and establish her own priorities B. Schedule a home visit in the afternoon to assess the son and client's role as caregiver C. Provide feedback to the client about her atonement for guilt and her son's impairment D. Acknowledge the client's stress and suggest that she consider respite care D. Acknowledge the client's stress and suggest that she consider respite care 4 The nurse plans to administer a scheduled dose of Toprol at 0900 to a client with HTN. At 0800 the nurse notes the the client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? A. Administer the Toprol immediately and monitor the client carefully until the heart rate increases B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP every 30 min C. Hold the scheduled dose of Toprol and notify HCP of the telemetry pattern D. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180 C. Hold the scheduled dose of Toprol and notify HCP of the telemetry pattern 5 A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline, the nurse should instruct the client to report which condition to the HCP? A. Anxiety B. Insomnia C. Muscle cramping D. Increased appetite C. Muscle cramping 6 In determining the client position for insertion of an indwelling catheter, it is most important for the nurse to recognize which client condition? A. High urinary pH B. Fever C. Abdominal ascites D. Orthopnea D. Orthopnea