A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Keep the room brightly lit while providing care.

Minimize verbal interaction with the client.

Monitor for change in speech.

Avoid dropping side rails or abruptly closing the door.

Report any change in level of consciousness.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Keeping the room brightly lit while providing care may help with orientation but is not a specific instruction related to stroke care.

Choice B reason: Minimizing verbal interaction with the client is not advisable. Communication is essential in assessing the client's neurological status.

Choice C reason: Monitoring for change in speech is important as speech difficulties can indicate a worsening of the stroke or other neurological issues.

Choice D reason: Avoiding dropping side rails or abruptly closing the door helps minimize unnecessary stimulation and agitation, which can be beneficial for a client experiencing a stroke.

Choice E reason: Reporting any change in level of consciousness is critical as it can indicate changes in the client's condition that require immediate medical attention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Intubation is not the first step in managing COPD exacerbation unless the client is in severe respiratory failure (e.g., unresponsive, unable to protect airway, pH severely low). This client is alert, able to maintain vitals, so less invasive interventions should be tried first.

Choice B reason: High-flow oxygen at 100% can eliminate the hypoxic drive to breathe in COPD patients, leading to CO₂ retention and respiratory acidosis. Controlled oxygen therapy (e.g., nasal cannula or Venturi mask at 1–2 L/min or FiO₂ 24–28%) is preferred.

Choice C reason: This "tripod" position reduces work of breathing by optimizing diaphragmatic expansion and helping accessory muscles function more effectively. It is an evidence-based immediate nursing intervention for acute dyspnea in COPD.

Choice D reason: Obtaining a sputum sample for culture and sensitivity is important for identifying the cause of the infection but is not the immediate priority.

A. Twin siblings admitted with scarlet fever that is complicated with pneumonia. B. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB). C. An older client with scabies who is admitted from an extended care facility. D. A female adolescent admitted with multiple genital Herpes simplex II lesions.

Correct Answer is B

Explanation

Choice A reason: Scarlet fever and pneumonia require droplet precautions, not airborne.

Choice B reason: A positive Mantoux test and positive sputum cultures for AFB indicate tuberculosis, which requires airborne precautions and a negative airflow room.

Choice C reason: Scabies requires contact precautions, not airborne.

Choice D reason: Genital Herpes simplex II requires standard precautions, not airborne.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is B

Explanation

A client with Parkinson's disease (PD) is admitted to the medical surgical unit and the nurse assesses the client's mobility needs. Which finding(s) indicate the need to plan interventions related to the client's mobility? Select all that apply.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

A client with a non-healing wound and excessive drainage is using a wound VAC system. The nurse notices increased drainage and signs of possible infection. What is the most appropriate nursing intervention?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.