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A nurse is caring for a client.

Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6° C (99.7° F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Select the 4 findings that require immediate follow-up.

Temperature

Blood pressure

Respiratory rate

Pulse oximetry.

Heart rate.

Level of consciousness

Skin color and temperature

Answer and Explanation

Correct Answer : B,D,E

The blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg.

The pulse oximetry has decreased from 97% to 93%, indicating a decrease in oxygen saturation.

The heart rate has increased from 66/min to 104/min.

The level of consciousness is always an important factor to monitor in a patient.

A. Temperature: The temperature has only changed slightly and is within the normal range.

C. Respiratory rate: The respiratory rate has increased but is still within normal range.

G. Skin color and temperature: This information is not provided in the exhibit.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.

B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.

C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.

D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.

A. Verify the count total of the controlled substance after removing the amount needed. B. Place the wasted portion of the controlled substance in the sharps container. C. Report any discrepancy in the count total of the controlled substance after administration. D. Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.

Correct Answer is D

Explanation

Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.
This is because if a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse.
Choice A is wrong because the count total of the controlled substance should be verified before removing the amount needed, not after.
Choice B is wrong because the wasted portion of the controlled substance should not be placed in the sharps container.
It should be disposed of according to facility/agency policy.
Choice C is wrong because any discrepancy in the count total of the controlled substance should be reported immediately, not after administration 1.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

What tort is committed by an assistive personnel who threatens to put a client in restraints for not following a provider's prescription for strict bed rest?

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult?

A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? (Select all that apply.).

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?