A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

This test will determine if your heart is performing properly."

This test will indicate if you are at risk for developing blood clots."

This test will provide information about the function of your liver."

This test is used to check how your kidneys are working."

Answer and Explanation

The Correct Answer is C

A tracheostomy is a surgical opening in the neck that allows air to enter the lungs through a tube called a tracheostomy tube. The tube has two parts: an outer cannula that stays in place and an inner cannula that can be removed for cleaning. The tracheostomy ties are used to secure the tube to the neck and prevent it from falling out. They should be adjusted to allow one finger to fit snugly underneath so that they are not too tight or too loose.

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Correct Answer is A

Explanation

Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.

A. Number of family members who have visited B. Time of the client's last bath C. Frequency of previous vital sign measurement D. Effectiveness of the last dose of pain medication

Correct Answer is D

Explanation

The hand-off report is a verbal or written communication that provides essential information about the client's care, treatment, current condition and anticipated needs during a transition of care. The hand-off report should include information that is relevant, accurate, concise and timely. The effectiveness of the last dose of pain medication is an important information that should be included in the hand-off report, as it reflects the client's current pain level, response to treatment and need for further intervention.

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A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Correct Answer is A

Explanation

A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-off report?

Correct Answer is D

Explanation

A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?

A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse hangs a bag of dextrose 5% in water 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is receiving enteral feedings via NG tube. Which of the following actions should the nurse take prior to administering the formula?

A nurse is speaking with the partner of a client who is unconscious and has a do-not resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?