1st Assessment for EVOLVE
A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action?
1. Monitor the maternal vital signs. *2. Notify the registered nurse (RN) immediately.* 3. Continue monitoring labor and the fetal heart rate. 4. Encourage relaxation and breathing techniques between contractions.
The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder?
1.An adolescent 2.An active elderly client 3.A physical education teacher *4.An outdoor construction worker*
A client with chronic kidney disease is receiving epoetin alfa (Epogen, Procrit). Which laboratory result should indicate a therapeutic effect of the medication?
*1. Hematocrit of 32%* 2.Platelet count of 400,000 cells/mm3 3.White blood cell count of 6000 cells/mm3 4.Blood urea nitrogen (BUN) level of 15 mg/dL
A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 am, 12 noon, and at 6:00 pm. What times should the nurse tell the mother to perform postural drainage?
1. 8:00 am, 2:00 pm, and 6:00 pm 2. 9:00 am, 1:00 pm, and 6:00 pm 3.8:00 am, 12:00 noon, and 6:00 pm *4.10:00 am, 2:00 pm, and 8:00 pm*
The nurse is collecting data from a client with a history of bladder cancer. Which sign/symptom is the client most likely to report?
1. Dysuria *2. Hematuria* 3. Urgency of urination 4. Frequency of urination
A licensed practical nurse (LPN) is assisting in the care of a client who is receiving oxytocin (Pitocin) to induce labor. The LPN plans to notify the registered nurse immediately if which is noted?
1. The client becomes drowsy. 2.The client complains of fatigue. *3.The uterus becomes hyperstimulated.* 4.There are early decelerations on the fetal heart rate monitor.
