A nurse is assessing a newly admitted client with a history of chronic heart failure who has new onset confusion after forgetting to take his medications for a few days. The client has peripheral edema, mild shortness of breath, and bilateral crackles in the lung bases. Which of the following assessments is the priority for the nurse?

Capillary refill and depth of peripheral edema

Abdominal sounds and obtain a BNP level

Neurological status and obtain electrolyte levels

Skin turgor and measure intake & output (I&O)

Answer and Explanation

The Correct Answer is C

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Teach the client a relaxation technique to use until the next dose is due: While relaxation techniques can be helpful in managing pain, they are not sufficient for severe pain rated 9/10. The client requires more immediate pharmacological intervention.
B. Obtain an order for an immediate-release opioid for breakthrough pain: This is the most appropriate action. Immediate-release opioids are specifically used to manage breakthrough pain in clients on sustained-release opioid therapy. It addresses the client's severe pain effectively and promptly.
C. Explain to the client that the medication being administered lasts for 12 hours: Simply explaining the duration of the medication does not address the client's current severe pain. Effective pain management requires action, not just education.
D. Assess the client's vital signs and administer the next dose of opioids early: Administering the next dose early can lead to inappropriate dosing schedules and potential overdose. It is important to follow the prescribed dosing regimen and manage breakthrough pain appropriately.

A. Deep breathing and coughing exercises daily B. Removal of compression stockings at night C. Floating the heels while lying in bed D. Leg exercises ten times per hour while awake

Correct Answer is D

Explanation

A. Deep breathing and coughing exercises daily: These are important for preventing respiratory complications but do not specifically address the prevention of thrombosis.
B. Removal of compression stockings at night: Compression stockings should generally be worn continuously to prevent venous stasis and thrombosis.
C. Floating the heels while lying in bed: This helps prevent pressure ulcers but is not a primary intervention for preventing thrombosis.
D. Leg exercises ten times per hour while awake: This is the correct choice. Regular leg exercises improve circulation and help prevent venous stasis, thereby reducing the risk of thrombosis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Correct Answer is B

Explanation

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombosis?

Correct Answer is D

Explanation

The nurse is providing care for several clients at risk for acid-base imbalance. Which client has the greatest risk for respiratory acidosis?

A client is experiencing respiratory depression, constipation, nausea and vomiting, and hypotension after receiving pain medication. Which class of analgesics did this client most likely receive?

The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure newly admitted to the critical care unit. What electrolyte imbalance is this client most likely experiencing?

A student nurse is working with their preceptor on a medical-surgical unit. While reviewing concepts related to acid-base balance, what should the preceptor state is a compensatory mechanism for metabolic alkalosis?

The pharmacy just delivered the sustained-release opioid tablets newly prescribed for a client with a gastrostomy tube. What should the nurse do when preparing to provide this medication to the client?

A nurse working in the post-anesthesia care unit (PACU) is caring for a post-operative client that just had pelvic surgery. The nurse anticipates assessing for what post-operative complaint related to spinal anesthesia?