A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?

A normal reaction to a position change.

Gait belt applied.

Orthostatic hypotension noted with dangling.

Elevated blood sugar probable.

Answer and Explanation

The Correct Answer is C

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

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Correct Answer is C

Explanation

The proper length of the needle to administer a subcutaneous injection depends on the amount of adipose tissue over the muscle.

The needle should be long enough to reach the subcutaneous layer but not so long that it penetrates the muscle. The needle gauge and length vary depending on the patient’s size and the injection site

Choice A is wrong because the age of the client does not determine the needle length.

However, age may affect the amount of adipose tissue and muscle mass, which are factors to consider when choosing a needle length.

Choice B is wrong because the viscosity of the solution does not determine the needle length. However, viscosity may affect the needle gauge, which is the diameter of the needle.

Thicker solutions may require larger gauge needles to allow easier flow.

Choice D is wrong because the quantity of the solution does not determine the needle length.

However, quantity may affect the syringe size, which is the volume of medication that can be held by the syringe.

The syringe size should match the prescribed dose as closely as possible to ensure accuracy and ease of measurement.

A. Do not eat or drink for 12 hours prior to the test. B. Eliminate all dietary cholesterol for one week before this test. C. Avoid caffeinated beverages for several days prior to the test. D. Stop eating eggs and drinking milk for two days before the test.

Correct Answer is A

Explanation

Do not eat or drink for 12 hours prior to the test. This is because fasting is required for a total serum cholesterol test to get accurate results. Fasting means not eating or drinking anything except water for 9 to 12 hours before the test.

Choice B is wrong because eliminating all dietary cholesterol for one week before the test is not necessary and will not affect the test results. Dietary cholesterol only accounts for a small portion of the total cholesterol in the blood.

Choice C is wrong because avoiding caffeinated beverages for several days prior to the test is not required and will not influence the test results. Caffeine does not affect cholesterol levels.

Choice D is wrong because stopping eating eggs and drinking milk for two days before the test is not needed and will not change the test results. Eggs and milk contain cholesterol, but they also have other nutrients that may lower the risk of heart disease.

Normal ranges for total serum cholesterol are less than 200 mg/dL (5.18 mmol/L) for adults. Higher levels may indicate an increased risk of heart disease and stroke.

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A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which criterion should a nurse use to determine the proper length of the needle to administer a subcutaneous (subcut) medication?

Correct Answer is C

Explanation

A client is scheduled for a “total serum cholesterol” lab test. Which instruction to the client should be discussed to ensure adequate preparation for the test?

Correct Answer is A

Explanation

Which is an important need for a widowed client during the grieving period following the death of the client’s spouse?

A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C). Which action should a nurse take next?

A client is prescribed olanzapine for schizophrenia. How will the nurse monitor the client for adverse side effects? (Select all that apply).

Which symptom experienced by a client receiving a continuous enteral feeding via a nasogastric tube requires priority follow-up by the nurse?

A client states “I have something to tell you in confidence.” Which response by the nurse would be appropriate?

An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia. Which of the following is the best reason for the assessment findings?

A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

Which instructions should a nurse give to a client prior to obtaining a throat culture?

A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?