A nurse is assessing a client whose therapy has included bed rest for several weeks.
Which of the following findings should the nurse identify as the priority?

Loss of appetite

Left lower extremity tenderness

Increased heart rate during physical activity

Musculoskeletal weakness

Answer and Explanation

The Correct Answer is B

A.   While decreased appetite may be concerning, it is not typically considered a priority over potential complications related to immobility.
B.   Left lower extremity tenderness could indicate deep vein thrombosis (DVT), a serious complication of prolonged bed rest that requires immediate attention to prevent pulmonary embolism.
C.   Increased heart rate during physical activity may be expected after a period of bed rest and can be addressed with gradual reconditioning.

D.   Musculoskeletal weakness is a common consequence of immobility and would be addressed as part of the client's rehabilitation but is not an immediate priority compared to potential complications like DVT.

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

Explanation

A. Comparing the medication administration record with the medication container should occur before documentation to ensure accuracy.
B. This step ensures that the nurse is administering the correct medication to the client.
C. Comparing the medication against the administration record while removing it from the container helps prevent errors.
D. While important, this step does not directly involve comparing the medication container with the administration record.
E. Verifying the medication at the bedside ensures the right medication is given to the right patient at the right time.

A. The client's pupils constrict in response to light. B. The client's tongue is in a midline position: C. The client has a symmetrical smile. D. The client turns their head against resistance.

Correct Answer is C

Explanation

A. This response is associated with cranial nerve II, the optic nerve.

B. Tongue position is associated with cranial nerve XII, the hypoglossal nerve.

C. A symmetrical smile is indicative of cranial nerve VII, the facial nerve.

D. This action is associated with cranial nerve XI, the accessory nerve.

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A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)

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

Explanation

A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

Correct Answer is C

Explanation

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A nurse is assessing a client whose therapy has included bed rest for several weeks.
Which of the following findings should the nurse identify as the priority?