Which of the following would the nurse expect to include in the plan of care for a client with diabetes who is in labor
A. Measuring urine output every 4 hours.
B. Monitoring blood glucose levels every hour.
C. Administering insulin subcutaneously every 4 hours.
D. Checking deep tendon reflexes every 2 hours.
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An 18-year-old primagravida tells the nurse that the physician told her that she needed to increase her intake of thiamine (vitamin Bi) in her diet. Which of the following foods should the nurse instruct the client to consume more
A. Milk.
B. Rice.
C. Asparagus.
D. Bee
The nurse assesses the client to determine the cause of autonomic dysreflexi().
A. Which of the following is the most common stimulus for an autonomic dysreflexia episodeA. Rising intracranial pressure.
Bowel distention.
C. Bladder distention.
D. Anxiety.
The nurse observes that the client’s total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next
Assess the infusion system, note the client’s condition, and notify the physician.
B. Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.
C. Increase the flow rate to infuse an additional 300 mL over the next hour.
D. Maintain the flow rate at the current rate and document any discrepancy in the chart.
A client in labor received an epidural anesthetic when her dilation reached 5 cm. Which of the following nursing diagnoses would have the highest priority for her at this time
A. Impaired skin integrity related to inability to move lower extremities.
B. Impaired urinary elimination related to the effects of the epidural.
C. Deficient knowledge related to lack of information about regional anesthesia.
D. Risk for injury related to hypotension secondary to vasodilation and pooling in extremities.
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