A nurse is reviewing the medical record of a client.

Exhibits

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+

Generalized weakness

mild leg cramping

Lungs clear

Heart rate irregular

Bowel sounds hyperactive x 4 quadrants

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Deep Tendon Reflexes 4+: This indicates hyperreflexia, which can be associated with electrolyte imbalances, particularly magnesium deficiency, or central nervous system issues. In this context, the client has a low magnesium level (0.7 mEq/L), which can cause neuromuscular irritability and potentially dangerous complications.

Generalized Weakness and Mild Leg Cramping: While muscle strength is reported as equal, the generalized weakness and cramping suggest possible electrolyte imbalances or neurological issues. The combination with low magnesium levels raises concern for further complications.

Heart Rate Irregular: An irregular heart rate can indicate potential cardiac issues, especially in the context of electrolyte imbalances such as hypomagnesemia and the use of hydrochlorothiazide, which can contribute to electrolyte disturbances.

Bowel Sounds Hyperactive x 4 Quadrants: Although hyperactive bowel sounds can be associated with various conditions, in this case, they may be linked to the client's history of vomiting and possible electrolyte imbalance, warranting follow-up to ensure appropriate management of gastrointestinal symptoms.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Orthostatic hypotension is not a direct risk factor for cardiovascular disease, though it can be related to other health issues.

B. Type 1 diabetes mellitus increases the risk for cardiovascular disease due to chronic hyperglycemia, which can damage blood vessels over time.

C. Osteoporosis is a risk for bone health but is not a cardiovascular risk factor.

D. A BMI of 24 is within the normal range and does not pose a cardiovascular risk.

A. Request a prescription renewal from the provider every 36 hr. B. Make sure two fingers fit under the restraints. C. Check the client's range of motion every 6 hr. D. Secure the restraints with a square knot.

Correct Answer is B

Explanation

A. Restraint prescriptions typically need to be renewed at least every 24 hours, not every 36 hours, to comply with regulatory standards.

B. Ensuring that two fingers fit under the restraints is essential to confirm that they are not too tight, allowing for circulation and comfort while still securing the client.

C. Checking the client's range of motion should occur more frequently than every 6 hours; ideally, it should be assessed more regularly to prevent complications.

D. Restraints should be secured using a quick-release knot, not a square knot, to ensure they can be removed easily in an emergency.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Correct Answer is B

Explanation

A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?

A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?

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.)