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A nurse is reviewing the medical record of a client

Exhibits

Click to highlight below the findings that require immediate follow-up.

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

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

deep tendon reflexes 4+

Heart rate irregular

Bowel sounds hyperactive x 4 quadrants

Generalized weakness with equal bilateral muscle strength and mild leg cramping

Lungs clear

Heart rate 95/min

Alert and oriented to person, place, and time;

Answer and Explanation

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

An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is E,B,C,D,A

Explanation

First, the nurse should apply clean gloves (E) to maintain sterility and safety. Next, the nurse should disconnect the tube from the suction device (B), ensuring that the device is no longer actively working on the tube.

Before removing the tube, it is important to instill air into it (C); this helps clear any residual contents and minimizes the risk of aspiration. The nurse should then ask the client to take a deep breath (D), which helps close the epiglottis to prevent aspiration during the removal of the tube. Finally, the nurse can pinch and withdraw the tube (A), completing the process in a swift, steady motion to ensure comfort and safety for the client.

A. Placing the restraint across the client's chest B. Applying the restraint over the client's gown C. Using a quick-release tie to secure the restraint D. Tying the restraint to the bed frame

Correct Answer is A

Explanation

A) Placing the restraint across the client's chest - This is not a safe practice since it can restrict breathing increasing the risk of asphyxiation.
B) Applying the restraint over the client's gown - Restraints should be applied over the clients gown and not directly to the client's skin to prevent friction and skin breakdown.
C) Using a quick-release tie to secure the restraint - Quick-release ties are important for ensuring that restraints can be quickly removed in case of an emergency.
D) Tying the restraint to the bed frame – Tying restraints on the bed frame is the recommended practice. Restraints should not be tied on the bed rails to avoid injuries if the side rails are released.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is E,B,C,D,A

Explanation

A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client Indicates an understanding of the instructions?