A nurse in a provider's office is caring for a male client.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The nurse is evaluating the client's response to the prescribed medications. The client's
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and
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indicate an improvement in the client's condition.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Answer: The nurse is evaluating the client's response to the prescribed medications. The client's blood pressure and HDL level indicate an improvement in the client's condition.

Blood pressure: The client's blood pressure decreased from 180/88 mm Hg to 138/70 mm Hg, which indicates an effective response to atenolol, a betablocker used for hypertension management.

HDL level: The HDL ("good cholesterol") increased from 25 mg/dL to 60 mg/dL, reflecting a positive response to simvastatin, which helps improve lipid profiles and reduce cardiovascular risk.

Heart rate: The heart rate dropped from 96/min to 58/min, which may be due to atenolol. While bradycardia is a side effect, it is only concerning if it drops below 50/min.

Weight: The client gained 4 kg (8.8 lb), which may indicate fluid retention and requires further assessment.

Potassium level: The potassium level increased from 4.2 to 5.3 mEq/L, likely due to spironolactone, a potassiumsparing diuretic. This is above the normal range and requires monitoring for hyperkalemia.

Pedal findings: The edema worsened from 2+ to 3+, indicating fluid retention and possible worsening heart failure, requiring intervention.

Pulse oximetry: The oxygen saturation slightly decreased from 97% to 95%, but this is within normal limits and does not indicate a significant clinical improvement or deterioration.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Hematuria. While hematuria (blood in the urine) can indicate potential complications such as radiationinduced cystitis or coagulopathy, it is not the most urgent concern in a client with brain cancer. It should be reported and monitored, but immediate intervention is typically not required unless accompanied by signs of hemorrhagic shock or renal dysfunction.
B. Chest pain and dyspnea. Chest pain and dyspnea could indicate serious conditions such as pulmonary embolism, pneumonia, or cardiotoxicity from cancer treatment. While these symptoms are concerning and require prompt evaluation, in the context of brain cancer, they are not the most immediate neurological emergency compared to seizures.
C. Seizures. This is the most critical symptom to report immediately. Clients with brain cancer are at high risk for seizures due to tumorrelated irritation of the cerebral cortex, increased intracranial pressure (ICP), or radiationinduced brain swelling. Seizures can lead to further neurological compromise, aspiration, or even status epilepticus, which is a lifethreatening emergency. Immediate intervention with seizure precautions, airway protection, and possible administration of anticonvulsants or corticosteroids is required.
D. Swelling of the extremities Swelling of the extremities may be due to lymphedema, deep vein thrombosis (DVT), or radiationinduced inflammation. While this symptom should be assessed, it does not pose an immediate lifethreatening risk compared to seizures in a client with brain cancer.

A. Performing the procedure independently B. Verbalizing all steps in the procedure C. Attending a class given about tracheostomy care D. Asking appropriate questions about suctioning

Correct Answer is A

Explanation

A. Performing the procedure independently. This is the best indicator of readiness for discharge. The client’s partner must demonstrate the ability to perform tracheostomy suctioning correctly and safely without direct supervision. Proper technique includes using sterile equipment, maintaining appropriate suction pressure (80120 mmHg), limiting suction duration to 1015 seconds per pass, and allowing adequate oxygenation between passes to prevent hypoxia. Independent performance ensures the caregiver can manage airway clearance at home.
B. Verbalizing all steps in the procedure. While verbalizing the steps demonstrates understanding, it does not confirm the ability to perform suctioning correctly. Practical application is necessary to ensure competency in technique, infection control, and recognizing complications such as hypoxia or airway trauma.
C. Attending a class given about tracheostomy care. Education is essential, but attending a class alone does not confirm skill mastery. Handson practice and independent demonstration are required to ensure safe and effective tracheostomy management.
D. Asking appropriate questions about suctioning. Asking questions reflects engagement and willingness to learn, but it does not indicate that the caregiver can independently perform the procedure. Proper discharge readiness requires demonstrated competency through handson practice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

Correct Answer is C

Explanation

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Correct Answer is A

Explanation

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable waterseal drainage system with suction. The nurse should intervene for which of the following observations?

A nurse is caring for a client. Exhibits Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following changes should the nurse expect? (Select All that Apply.)

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS). The nurse should identify that which of the following conditions is the most common cause of ARDS?