A client who is in the end stage of chronic bronchitis tells the nurse, “I don’t know how my wife will manage without me.” The most appropriate response by the nurse at this time is:

Would you like to see a member of the clergy to receive a blessing?

Do you have children who can help your wife?

Do you have a living will?

Have you discussed your feelings with your wife?

Answer and Explanation

The Correct Answer is D

Choice A reason: Asking if the client would like to see a member of the clergy to receive a blessing can be supportive, but it may not directly address the client’s immediate emotional needs. While spiritual support is important, the nurse should first focus on the client’s expressed concerns about their wife.

Choice B reason: Inquiring if the client has children who can help their wife is practical, but it may not address the client’s emotional distress. The nurse should prioritize providing emotional support and facilitating communication between the client and their family.

Choice C reason: Asking if the client has a living will is important for end-of-life planning, but it does not directly address the client’s emotional concerns. This question is more appropriate for a discussion about advance directives rather than an immediate response to the client’s expressed worries

Choice D reason: Encouraging the client to discuss their feelings with their wife is the most appropriate response. It addresses the client’s emotional needs and promotes open communication between the client and their spouse. This can help alleviate some of the client’s anxiety and ensure that their wife is aware of their feelings and concerns.

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Correct Answer is D

Explanation

Choice A Reason:

Notifying the surgeon of the blood pressure is important, but it is not the first action the nurse should take. The primary concern is to manage the patient’s high blood pressure to prevent any complications during surgery. Once the blood pressure is under control, the nurse can then notify the surgeon if necessary.

Choice B Reason:

Documenting the blood pressure on the pre-op checklist is a necessary step, but it is not the immediate priority. The nurse’s first action should be to address the elevated blood pressure to ensure the patient’s safety. Documentation can be done after the immediate concern is managed.

Choice C Reason:

Having the client relax and take deep breaths can help lower blood pressure temporarily, but it is not a sufficient intervention for a blood pressure reading as high as 174/88. The nurse should take a more direct approach to manage the hypertension, such as administering the prescribed antihypertensive medication.

Choice D Reason:

Administering the antihypertensive medication is the most appropriate first action. The patient is NPO (nothing by mouth) except for medications, indicating that the medication should still be given. This action directly addresses the elevated blood pressure and helps to stabilize the patient before surgery.

A. Sunday morning B. Saturday morning C. Friday morning D. Monday morning

Correct Answer is A

Explanation

The tuberculin skin test (TST), also known as the Mantoux test, is used to determine if a person has been infected with the tuberculosis (TB) bacteria. The test involves injecting a small amount of purified protein derivative (PPD) into the skin of the forearm. The injection site is then examined 48 to 72 hours later for a reaction, which is measured in millimeters of induration (swelling).

Choice A reason:

Sunday morning is the correct time to read the test results. Since the test was administered on Thursday at 1200, the 48 to 72-hour window for reading the results would fall between Saturday at 1200 and Monday at 1200. Reading the results on Sunday morning falls within this time frame, making it the appropriate choice.

Choice B reason:

Saturday morning is not the correct time to read the test results. Reading the test results on Saturday morning would be less than 48 hours after the test was administered, which is too early to accurately assess the reaction. The test needs to be read between 48 and 72 hours after administration to ensure accurate results.

Choice C reason:

Friday morning is also not the correct time to read the test results. Reading the test results on Friday morning would be only 24 hours after the test was administered, which is far too early. The immune response to the PPD injection takes time to develop, and reading the test too early can result in a false-negative result.

Choice D reason:

Monday morning is within the acceptable time frame to read the test results, but it is at the very end of the 72-hour window. While it is still technically correct, it is generally recommended to read the test closer to the 48-hour mark to ensure the most accurate results. Therefore, Sunday morning is a better choice.

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A client who is in the end stage of chronic bronchitis tells the nurse, “I don’t know how my wife will manage without me.” The most appropriate response by the nurse at this time is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who receives an antihypertensive medication daily is NPO except medications for surgery. The most recent blood pressure recording is 174/88. What action should the nurse take first?

Correct Answer is D

Explanation

A client receives a tuberculin (PPD) skin test on Thursday at 1200. The nurse documents on the medication record that the results need to be read:

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that they have a frequent productive cough and shortness of breath. The nurse should anticipate which of the following assessment findings for this client?

The nurse is performing a physical assessment on the respiratory system. Although the client is currently confined to bed, they have the strength and ability to move and reposition themselves. The nurse instructs the client to assume which position for the assessment?

The priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:

The nurse recognizes that the primary physiologic problem affecting clients with emphysema is:

A client is diagnosed with asthma. The therapeutic regimen using metered dose inhalers includes albuterol 2 puffs and beclomethasone 2 puffs. The nursing plan of care must include teaching regarding:

The nurse recognizes the assessment data which best indicates that the client diagnosed with asthma is achieving good control with the prescribed medication regimen is when:

Which of the following is a characteristic of a Venturi mask?

The nurse is evaluating the arterial blood gas (ABG) of a client who was admitted in status asthmaticus. Which ABG result would indicate the client has an improved acid-base status?