125.

A nonstress test is scheduled for a client at 34-weeks gestation who

developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to
BEST prepare the client for the diagnostic test?
1.
2.
3.
4.

Start an intravenous line for an oxytocin infusion.

Obtain a signed consent prior to the procedure.
Instruct client to push a button when she feels fetal movement.
Attach a spiral electrode to the fetal head.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) would be appropriate for an oxytocin (stress) test
(2) is incorrect because this is noninvasive
(3) correctnonstress test is a noninvasive test to evaluate the response of the fetal
heart rate to the stress of fetal movement; response will be reflected on the fetal
monitor
(4) prepares for internal fetal monitoring
126. A client is in cardiogenic shock after a myocardial infarction (MI).
Which of the following is a correctly stated nursing diagnosis for this client?
1.
2.
3.
4.

Activity intolerance: related to impaired oxygen transport.

Altered tissue perfusion related to decreased heart-pumping action.
Altered cardiac output related to cardiac ischemia.
Potential fluid volume deficit related to decreased intake.

Strategy: Think about each answer choice.

(1) a colon is not acceptable punctuation when stating a nursing diagnosis
(2) correctcorrectly stated, appropriate nursing diagnosis
(3) altered cardiac output is not a commonly accepted nursing diagnosis
(4) not appropriate for this client
127. The client is exhibiting symptoms of myxedema. The nursing
assessment should reveal
1.
2.
3.
4.

increased pulse rate.

decreased temperature.
fine tremors.
increased radioactive iodine uptake level.

Strategy: Determine how each answer choice relates to myxedema.

(1) pulse will decrease
(2) correctwith myxedema there is a slowing of all body functions
(3) associated with hyperthyroidism
(4) associated with hyperthyroidism