A nurse is caring for a client on a medical-surgical unit.

Exhibits

Click to highlight the findings below of the prescriptions that the nurse should clarify with the provider prior to administering the medications. To deselect a finding, click on the finding again.

1300:

Potassium Chloride 20 mEq PO daily

HCTZ 25mg QD

Amlodipine 10 mg QOD

Clonidine .1 mg PO TID PRN blood pressure > 180 systolic

HCTZ 25mg QD

QOD

.1 mg

> 180 systolic

Amlodipine

Answer and Explanation

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

When analyzing cues, the nurse should identify HCTZ, QD, QOD .1 mg, and >180mg systolic as error-prone abbreviations. Medications names, such as hydrochlorothiazide, should be spelled out. QD should be written as daily and QOD should be written as every other day. Decimal points should be written using a leading zero and greater than and less than should be written out rather than using symbols.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Apply firm, direct pressure to the catheter insertion site is the best first action because it directly addresses the immediate concern of bleeding, helping to prevent excessive blood loss and stabilize the client.

Assess vital signs and assess for signs of hypovolemia is the best next action, as the client's increasing heart rate and decreasing blood pressure suggest potential blood loss, which could lead to hypovolemic shock.

Incorrect answers;

Lowering the head of the bed and assessing circulation (B in i) is important but should follow bleeding control.

Increasing IV fluids (C in i) may be necessary but should be done based on provider orders after controlling bleeding.

Preparing for fluid resuscitation (B in ii) is relevant but is not the first step; monitoring vitals is a more immediate priority.

Notifying the provider (C in ii) is crucial but should occur after assessing the client's status to provide accurate information.

A. Numerical pain scale B. Verbal description C. FACES pain scale D. Behavioural indicators

Correct Answer is D

Explanation

A. Numerical pain scale. Clients with dementia often have difficulty understanding and using numerical pain scales.

B. Verbal description. Many clients with dementia have impaired verbal communication, making it difficult to describe pain effectively.

C. FACES pain scale. While this scale is useful for some nonverbal populations, it still requires the client to actively choose a face, which may be difficult for those with advanced dementia.

D. Behavioral indicators. Observing facial expressions, body movements, vocalizations, and changes in vital signs can help assess pain in clients who cannot self-report. The PAINAD (Pain Assessment in Advanced Dementia) scale is commonly used.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client on a medical-surgical unit. Exhibits Complete the following sentence by using the list of options. The nurse should dropdown and then dropdown

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

Explanation

A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

Correct Answer is D

Explanation

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