A nurse is caring for a client.

Exhibits

Complete the following sentence by using the list of options.

The first two actions the nurse should take are
_
and
_

Answer and Explanation

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

Place the client in a private room (Option 1): Given the positive test results for tuberculosis (TB) exposure, placing the client in a private room is crucial for infection control. This helps prevent the spread of TB, which is a highly contagious disease, to other patients and healthcare staff. Isolation is a standard precaution for patients suspected of having active TB.

Apply supplemental oxygen (Option 2): The client's oxygen saturation is low at 88% on room air, indicating hypoxemia. Administering supplemental oxygen is essential to improve the patient's oxygen levels, ensure adequate tissue perfusion, and address any respiratory distress the patient may be experiencing.

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Correct Answer is B

Explanation

A. Rapid chewing is not specific to dysphagia.

B. A garbled or "wet" voice is often a sign of dysphagia, as it can indicate difficulty with swallowing and risk for aspiration.

C. Sneezing is not typically associated with swallowing difficulties.

D. Increased hunger is unrelated to dysphagia and does not indicate difficulty swallowing.

A. Apply the belt restraint over the client's gown. B. Tie the belt restraint to the side rail of the bed. C. Check the client's skin integrity every 4 hr. D. Make sure four fingers fit between the restraint and the client's body.

Correct Answer is A

Explanation

A. Applying the restraint over the client’s gown protects the skin and ensures comfort.

B. Restraints should never be tied to the side rail as it could lead to injury if the bed is adjusted; they should be tied to a stable part of the bed frame.

C. Skin integrity should be checked more frequently than every 4 hours to prevent injury.

D. Typically, two fingers, not four, should fit between the restraint and the client’s body to ensure it’s secure but not too tight.

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Body system	Findings
Neurological	Alert and oriented to person, place, and time: deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	Lungs clear
Cardiovascular	Heart rate irregular: Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options. The first two actions the nurse should take are ___ and ___

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options The client is at risk for developing ___ as evidenced by the client's ___

A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?

A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?

A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?

A nurse is caring for a client.

Exhibits

Complete the following sentence by using the list of options.

The first two actions the nurse should take are
_
and
_