A nurse in a clinic is caring for an older adult client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Digoxin Toxicity: The client’s symptoms (nausea, vomiting, diarrhea, weakness), vital signs (bradycardia), and lab results (high digoxin level, low potassium and magnesium) suggest digoxin toxicity.

Cardiac Monitor: To detect any arrhythmias resulting from digoxin toxicity.

Icterus: To assess liver function, which could be impacted in severe toxicity.

Electrolytes: Imbalances in potassium and magnesium can worsen digoxin toxicity and need to be corrected.

Fever: The fever might indicate an infection or inflammatory process, which can affect treatment and recovery.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Slurred speech can indicate increased ICP as it may affect neurological function.

B. Headache is a common symptom of increased ICP.

C. Pupillary changes can indicate increased ICP, affecting cranial nerve function.

D. Neck pain and stiffness are more associated with meningitis or other conditions, not specifically increased ICP.

E. Disorientation can be a sign of increased ICP affecting brain function.

A. Eyelets are not visible B. Movement of the trachea toward the unaffected side C. Crepitus in the area above and surrounding the insertion site D. Bubbling of the water in the water seal chamber with exhalation

Correct Answer is B

Explanation

A. The visibility of the eyelets on the chest tube is not a critical indicator for immediate notification unless other issues are present.
B. Movement of the trachea toward the unaffected side can indicate tension pneumothorax or other significant issues requiring immediate intervention.
C. Crepitus around the insertion site can indicate subcutaneous emphysema, which may be a complication but not an immediate emergency.
D. Bubbling in the water seal chamber during exhalation is a normal finding, as it indicates that the chest tube is functioning to allow air to escape.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is B

Explanation

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

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