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A male client has right-sided hemiplegia following a left cerebrovascular accident
(CVA). His sitting balance has improved, and he is now able to sit In a wheelchair.
To assist the client in transferring from the bed to a wheelchair, what action should
the nurse take?
A) Have the client put both arms around the nurse’s neck
for support. B) Place the wheelchair on the client’s left
side.
C) Instruct the client to look at his feet.
D) Instruct the client total slow, deep breaths while transferring.
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a
diagnosis of eclampsia. She is not presently convulsing. Which intervention should
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the nurse plan to include in this client’s nursing care plan?
A) Keep an airway at the bedside
B)Assess temperature every hour
C)Monitor blood pressure, pulse, and respirations every 4 hours ?
D)Allow liberal family visitation
The 2-hour exam a newborn delivered by cesarean section reveals nasal flaring,
visible retractions, audible grunting, and a dusky skin color. Current vital signs are:
axillary temp 98.5 F, pulse 148 beats/minute, and respiration 67 breaths/minute.
Which intervention should the nurse implement first?
A) Determine the infant’s blood glucose level
B) Delay giving the infants initial bath for one hour
C) Notify the healthcare provider of the infants current status ?
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D) Place a pulse oximeter on the infants foot
A primipara client at 42-weeks gestation is admitted for induction. Within one
hour after initiating an oxytocin (Pitocin) infusion, her cervix is 100% effaced and
6cm dilated, contractions are occurring every 1 minute with a 75 second duration.
The nurse stops the Pitocin and starts oxygen. After 30 minutes of uterine rest, the
contractions are occurring every 5 minutes with a 20 second duration. Which
intervention should the nurse implement?
A) Stop oxygen per canula
B) Check for clonus in both feet
C) Notify nursery about the clients response ?
D) Restart Pitocin infusion rate per protocol
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