A nurse enters a client’s room to answer the call light and finds the client on the bathroom floor. What should be the nurse’s initial action?

Assist the client back into bed.

Notify the client’s provider.

Inform the client’s family member.

Obtain the client’s vital signs.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D.

Choice A rationale:

Assisting the client back into bed is not the initial action. Moving the client without assessing their condition could potentially cause harm.

Choice B rationale:

Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.

Choice C rationale:

Informing the client’s family member is not the immediate priority. The nurse should first ensure the client’s safety and assess their condition.

Choice D rationale:

Obtaining the client’s vital signs is the initial action. This helps assess the client’s current condition and determine if there are any immediate medical needs.

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Correct Answer is D

Explanation

Choice A rationale:

Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.

In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.

It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.

Choice B rationale:

A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.

A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.

Choice C rationale:

A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:

Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.

A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.

A. Crackles B. Stridor C. Strong cough D. Deep breathing

Correct Answer is B

Explanation

Choice B rationale:

Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:

Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.

Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.

Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.

Blood or secretions in the airway: These can obstruct the airway and cause stridor.

It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:

Oxygen therapy: This can help to improve the patient's breathing.

Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.

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A nurse enters a client’s room to answer the call light and finds the client on the bathroom floor. What should be the nurse’s initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Correct Answer is D

Explanation

A nurse is assessing a patient following the removal of the patient’s endotracheal tube. Which finding should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is providing postoperative care for a patient who has a closed-wound drainage system. Which of the following actions should the nurse perform?

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A nurse is monitoring a patient who is receiving a blood transfusion. Which of the following symptoms should the nurse report to the charge nurse as a sign of an allergic blood transfusion reaction?

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A nurse is caring for a client who is receiving a transfusion of packed red blood cells and develops itching and hives. What should be the nurse’s first response?