Free NCLEX-RN Exam Braindumps (page: 79)

Page 79 of 431

In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:

  1. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
  2. Cover the cord with a wet sponge.
  3. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
  4. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.

Answer(s): D

Explanation:

(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.



In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:

  1. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
  2. Cover the cord with a wet sponge.
  3. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
  4. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.

Answer(s): D

Explanation:

(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.



A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:

  1. Client promises that he will not abuse aprazolam after discharge
  2. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life
  3. Client is able to verbalize effects of substance abuse on the body
  4. Client has remained substance free during hospitalization and is discharged

Answer(s): B

Explanation:

(A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself.



A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:

  1. Client promises that he will not abuse aprazolam after discharge
  2. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life
  3. Client is able to verbalize effects of substance abuse on the body
  4. Client has remained substance free during hospitalization and is discharged

Answer(s): B

Explanation:

(A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself.



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