when caring for a client with a possible diagnosis of placenta previa which of the following admission procedures should the nurse omit when caring for a client with a possible diagnosis of placenta previa which of the following admission procedures should the nurse omit
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Nursing Elites

NCLEX NCLEX-PN

Quizlet NCLEX PN 2023

1. When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?

Correct answer: enema

Rationale: The correct answer is 'enema.' Administering an enema to a client with placenta previa can dislodge the placenta, leading to an increased risk of bleeding and complications. It is crucial to avoid any interventions that may disrupt the placenta's positioning. Collecting urine and blood specimens are necessary for diagnostic purposes and monitoring, while a perineal shave is a routine procedure that does not pose a risk to the client with placenta previa.

2. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

Correct answer: The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.

Rationale: The correct answer is C because the client should breathe normally during a central venous pressure monitor reading. Placing the client in a supine position (Choice A) is correct if the client can tolerate it. Turning the stop-cock off (Choice B) and noting the level at the top of the meniscus (Choice D) are also correct actions during CVP monitoring. Instructing the client to perform the Valsalva maneuver is incorrect as it can artificially alter the CVP reading, indicating a need for further teaching.

3. Which of the following indicates a hazard for a client on oxygen therapy?

Correct answer: The client is wearing a synthetic gown.

Rationale: The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.

4. When discussing birth control methods with a client, what major factor should a nurse focus on to provide the motivation needed for consistent implementation of a birth control method?

Correct answer: Personal preference

Rationale: When discussing birth control methods with a client, a nurse should focus on the client's personal preference as a major factor that will provide the motivation needed for consistent implementation of a birth control method. Personal preference plays a key role in ensuring that the chosen method aligns with the client's lifestyle and values, increasing the likelihood of adherence. While work and home schedules, family planning goals, and the desire to have children in the future can influence the choice of birth control method, they are not the primary motivating factors for consistent implementation. Personal preference is crucial as it empowers the client to select a method that suits their individual needs and preferences, ultimately leading to better compliance and effectiveness.

5. A nurse discusses staff empowerment with the nursing team. The nurse explains that staff empowerment has which function?

Correct answer: Fosters the growth of others so that they are less dependent on the leader

Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. This empowerment is about enhancing skills and autonomy, not about reprimanding or punishing others (Choice B). Empowerment involves shared decision-making and autonomy, not unilateral decision-making by the leader (Choice C). Moreover, staff empowerment does not mean that staff should make every decision regarding operational aspects like employee scheduling (Choice D). It is primarily focused on developing individuals' capabilities and fostering independence within the team.

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