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A nurse is assisting with the care of a client who is postoperative.

Exhibits

Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again.

Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again.

Temp 37.5°C 99.5 F

Client is difficult to arouse

Respirations 10/min

Pulse oximetry 86% on room air

BP is 96/60 mm Hg

Temp 37.5°C 99.5 F

Client is difficult to arouse

Respirations 10/min

BP is 96/60 mm Hg

Pulse oximetry 86% on room air

Answer and Explanation

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

Temp 37.5°C (99.5°F):

This temperature is within normal range and doesn’t require immediate action.

Client is difficult to arouse:

Requires action. This could indicate oversedation or respiratory depression from morphine.

Respirations 10/min:

Requires action. This is on the low side, especially after opioid use. It indicates respiratory depression.

Pulse oximetry 86% on room air:

Requires action. This level is critically low and suggests hypoxia—requires oxygen and immediate follow-up.

BP is 96/60 mm Hg:

Requires action. This is low for a client whose BP was 162/84 an hour earlier, indicating a possible adverse reaction or hemodynamic instability.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Biofeedback:

Biofeedback involves using electronic monitoring to gain control over body functions (e.g., heart rate, muscle tension), not simply listening to music.

B. Guided Imagery:

Guided imagery involves mentally visualizing peaceful scenes or images, usually with a narrator guiding the process-not passive listening to music alone.

C. Distraction:

Music listening serves as a distraction, a nonpharmacologic method to divert attention away from pain.

D. Meditation:

Meditation typically involves focused breathing or mindfulness, not simply listening to music without intentional meditative practice.

A. Numbness B. Pallor C. Cool skin D. Edema

Correct Answer is D

Explanation

A. Numbness:

Not a common sign of thrombophlebitis. May indicate nerve compression, not vein inflammation.

B. Pallor:

Pallor suggests arterial issues, such as poor perfusion. Thrombophlebitis affects veins, typically not causing pallor.

C. Cool skin:

Cool skin is also associated with arterial insufficiency. In thrombophlebitis, the area may be warm and tender.

D. Edema:

Edema occurs due to impaired venous return and inflammation, which is typical in thrombophlebitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is about to undergo a closed reduction of a fracture. In addition to analgesia, the nurse suggests that the client listen to an audiotape of music. Which of the following nonpharmacologic interventions for pain management is the nurse using?

Correct Answer is C

Explanation

A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

Correct Answer is D

Explanation

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?

A nurse is reinforcing teaching with a newly licensed nurse about a nonrebreather mask. Which of the following statements should the nurse include?

A nurse is reinforcing teaching with a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?

A nurse is reinforcing preoperative teaching for a client about coughing and deep breathing, which of the following statements should the nurse make?

A nurse is caring for a client who is 1 day postoperative following surgery and reports incisional pain. Which of the following actions should the nurse take first?

A nurse is reviewing the past medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication?