Ati Comprehensive Online Practice Version A
Version A
1. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy
... [Show More] lochia. Which of the following actions should the nurse take first?
Administer oxygen.
The nurse should administer oxygen to improve gas exchange. However, there is another action the nurse should take first.
Initiate an infusion of oxytocin.
The nurse should initiate an infusion of oxytocin to promote uterine contractions. However, there is another action the nurse should take first.
Massage the uterus to expel clots.
MY ANSWER
Using the airway, breathing, circulation approach to client care, the nurse should place the priority on massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding.
Obtain a CBC.
The nurse should obtain a CBC to monitor the status of the client. However, there is another action the nurse should take first.
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A nurse is caring for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan?
Keep the client resting in bed.
A client who has a CN II deficit does not require bed rest.
Ask the client to restate directions.
The nurse should plan to ask clients who have a CN VIII deficit, which causes hearing loss, to restate directions.
Clear objects from the client's walking area.
MY ANSWER
The nurse should plan to clear objects from the client's walking area because a CN II deficit can result in visual impairment and lead to falls.
Evaluate the client's ability to swallow.
The nurse should plan to evaluate the swallowing ability of clients who have a CN IX deficit because it can impair swallowing.
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labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?
Continue observing the fetal heart rate.
MY ANSWER
Early decelerations indicate the progression of labor and are a benign finding. The nurse should continue to observe the fetal heart rate. [Show Less]