A male client is admitted to the emergency department (ED) while vomiting dark brown, foul-smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?

Place an indwelling urinary catheter and attach a bedside drainage unit.

Give a prescribed analgesic for temperature above 101°F (38.3°C), orally.

Send the client to x-ray for a flat plate of the abdomen.

Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS).

Answer and Explanation

The Correct Answer is D

Choice A reason: Placing an indwelling urinary catheter is not immediately relevant to the client's symptoms.

Choice B reason: Giving an analgesic for a fever does not address the underlying issue of bowel obstruction.

Choice C reason: Sending the client to x-ray can help diagnose the issue but is not the first action to relieve symptoms.

Choice D reason:

The correct answer is d) because inserting a nasogastric tube and attaching it to low intermittent suction helps decompress the stomach and relieve symptoms of bowel obstruction.

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Correct Answer is C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

A. Breathe deeply, followed by coughing up the sputum. B. Restrict fluids before expectorating the sputum specimen. C. Obtain the specimen before bedtime. D. Avoid mouth care prior to collecting the sputum.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because taking deep breaths followed by coughing helps produce a sputum sample from the lungs, which is necessary for accurate diagnostic testing.

Choice B reason: Restricting fluids before expectorating the sputum specimen is not necessary and may make it more difficult to produce a sample.

Choice C reason: Sputum specimens are best collected in the morning when secretions have accumulated overnight.

Choice D reason: Mouth care should be performed prior to sputum collection to reduce contamination from oral bacteria.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum sample?

Correct Answer is A

Explanation

A client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review?

Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

An older adult client with long-term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long-term complications? Select all that apply.

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

Which client has the highest risk for developing skin cancer?

A client with a new diagnosis of glaucoma is concerned about going blind. To help prevent blindness due to glaucoma, the nurse should instruct the client to implement which action(s)? Select all that apply.

A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance. Which action should the nurse implement?