A nurse is assisting with the care of a client on a medical surgical unit who was admitted from the emergency department.

Exhibits

For each assessment finding on Day 2 click to specify if the finding is due to lisinopril, carvedilol, or furosemide. Each finding may be related to more than 1 medication.

Calcium level

Potassium level

Sodium level

Edema

Oxygen saturation

Blood pressure

Weight

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B"},"G":{"answers":"B,C"}}

Calcium level: Decreased due to furosemide, a loop diuretic that increases calcium excretion in the urine, leading to mild hypocalcemia.
Potassium level: Decreased due to furosemide, which causes potassium loss through diuresis. Lisinopril, an ACE inhibitor, can cause potassium retention, but in this case, the effect of furosemide dominates.
Sodium level: Decreased due to furosemide-induced diuresis, which can lead to hyponatremia by excessive sodium loss.
Edema: Improved due to furosemide, which promotes fluid removal and reduces volume overload associated with heart failure.
Oxygen saturation: Improved due to carvedilol, which reduces heart failure symptoms by decreasing myocardial oxygen demand and improving cardiac output.
Blood pressure: Lowered due to both carvedilol (a beta-blocker) and lisinopril (an ACE inhibitor), both of which reduce systemic vascular resistance.
Weight: Decreased due to both carvedilol, which helps manage fluid retention over time in heart failure, and furosemide, which directly reduces fluid overload through diuresis.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Postoperative ambulation is important for recovery and preventing complications such as deep vein thrombosis, but it is not the most critical focus in the immediate preoperative period for a client undergoing a total laryngectomy.
B. Stoma site cleaning is the priority for the nurse to reinforce. After a total laryngectomy, the client will have a permanent stoma (opening) in the neck for breathing. Proper care and cleaning of the stoma site are essential to prevent infection, maintain airway patency, and ensure the client can manage their new method of breathing effectively.
C. Pain management is an important aspect of postoperative care, but it is secondary to ensuring that the client understands how to care for their stoma. Addressing pain is essential for comfort, but it does not take precedence over the immediate care required for the stoma.
D. Coughing and deep breathing are important for maintaining lung function and preventing complications such as pneumonia after surgery, but they are not the most critical teaching point for a client who will have a stoma after a total laryngectomy. The priority should be on the specific care of the stoma to ensure safety and effective breathing postoperatively.

A. Position the car seat at a 90° angle. B. Keep the airbag on if the car seat is in the front seat. C. Put a small cushion under the newborn's head for support. D. Place the shoulder harnesses at the level of the infant's shoulders.

Correct Answer is D

Explanation

A. "Position the car seat at a 90° angle." Positioning the car seat at a 90° angle is not recommended. The car seat should be reclined at an angle of 30 to 45 degrees to ensure that the infant's head does not flop forward, which can obstruct the airway.
B. "Keep the airbag on if the car seat is in the front seat." Keeping the airbag on when a car seat is in the front seat is unsafe. It is recommended to place the car seat in the back seat, as the force of an airbag deploying can be harmful to a child in a car seat.
C. "Put a small cushion under the newborn's head for support." Placing a cushion under the newborn's head is not recommended, as it can interfere with the proper positioning of the car seat and compromise the safety of the infant. The car seat is designed to provide support without additional cushions.
D. "Place the shoulder harnesses at the level of the infant's shoulders." Placing the shoulder harnesses at the level of the infant's shoulders is the correct practice. The harnesses should be positioned snugly at or just above the shoulders for optimal safety, ensuring that the infant is securely restrained in the car seat.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing preoperative teaching with a client who is scheduled for a total laryngectomy. Which of the following information is the priority for the nurse to reinforce?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

A nurse is assisting with the care of an adolescent. Exhibits Complete the following sentence by using the lists of options. The adolescent is at risk for developing dropdownevidenced bydropdown

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse include?

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is caring for a client who is at 26 weeks of gestation. Which of the following statements indicates the client is having difficulty accepting the body image changes associated with pregnancy?