A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.

Exhibits

Complete the following sentence by selecting the most appropriate actions based on the client’s current status.

The nurse should first
dropdown
then
dropdown
.

Answer and Explanation

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

The nurse should first: Response 1: Notify the primary health care provider immediately.

This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.

Then, the nurse should: Response 2: Start an IV line for potential medication administration.

Starting an IV line ensures that the client can receive any necessary medications quickly.

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Correct Answer is A

Explanation

Choice A rationale

Placing an identification tag on the outside of the client's shroud is essential for proper identification, especially in cases requiring an autopsy. This practice ensures that the deceased person is accurately identified throughout the process and helps prevent any mix-ups or misidentifications.

Choice B rationale

Asking the assistive personnel to document the client's time of death is incorrect as it is the nurse's responsibility to document the time of death accurately in the medical records, not the assistive personnel's duty.

Choice C rationale

Wearing sterile gloves when cleaning the client's body is not necessary. Standard precautions and the use of non-sterile gloves are sufficient for postmortem care unless there are specific reasons requiring sterility, which is uncommon.

Choice D rationale

Removing the client's dentures and giving them to the client's family is incorrect for an autopsy case. Dentures should be left in place to maintain the integrity of the body and to ensure that all personal effects are accurately documented and managed.

A. A client who has ulcerative colitis. B. A client who has cholecystitis. C. A client who uses laxatives. D. A client who has stomatitis.

Correct Answer is A

Explanation

Choice A rationale

Ulcerative colitis often results in inflammation and ulcers in the colon lining, which can lead to bleeding and a positive fecal occult blood test. This is a common complication of the condition.

Choice B rationale

Cholecystitis, an inflammation of the gallbladder, does not typically cause gastrointestinal bleeding or a positive fecal occult blood test. It is more associated with abdominal pain and digestive issues.

Choice C rationale

The use of laxatives generally does not cause internal bleeding that would result in a positive fecal occult blood test. Laxatives are more likely to cause changes in bowel habits and diarrhea.

Choice D rationale

Stomatitis, inflammation of the mouth, is unlikely to cause a positive fecal occult blood test. It primarily affects the oral cavity and is not associated with gastrointestinal bleeding. .

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Naxlex Comprehensive Predictor Exams

A nurse is planning to provide postmortem care for a client who requires an autopsy.Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory reports of four clients.Which of the following clients should the nurse expect to have a positive fecal occult blood test?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder.Which of the following statements by a family member indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client about blood glucose monitoring.The client becomes quiet and appears distracted while the nurse is providing the instructions.Which of the following responses should the nurse make?

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints.Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder.As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles.”. Which of the following actions should the nurse take?

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A nurse is caring for an older adult client who has fecal incontinence.Which of the following actions should the nurse take?

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality.In which of the following situations can the nurse disclose health information without the client's written consent?