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A nurse on a medical-surgical unit is admitting a client.

Exhibits

Click to highlight the action that would be appropriate for the care of the client. Each body system may support more than 1 potential action. To deselect an action, click on the action again.

Body System

Action

Cardiopulmonary

Inform client to achieve two to four breaths per session when using incentive spirometer.

Encourage deep-breathing exercises.

Check for pain.

Gastrointestinal

Encourage the client to increase fiber in their diet.

Promote intake of oral fluids.

Apply barrier ointment after bowel movements.

Encourage deep-breathing exercises

Check for pain

Promote intake of oral fluids

Apply barrier ointment after bowel movements

Answer and Explanation

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

Cardiopulmonary:

Encourage deep-breathing exercises.
Check for pain.

Rationale:

Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.

Checking for pain is essential as the client has been prescribed PRN morphine for pain management.

"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.

Gastrointestinal:

Promote intake of oral fluids.
Apply barrier ointment after bowel movements.

Rationale:

Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.

Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.

"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. A 21-year-old client who had a normal Pap test one year ago. The American Cancer Society (ACS) and the U.S. Preventive Services Task Force (USPSTF) recommend that cervical cancer screening (Pap test) begin at age 21, regardless of sexual history. Screening should be done every 3 years for individuals aged 21-29, assuming results are normal. Since this client had a Pap test one year ago, they do not need immediate screening but should follow the standard 3-year interval.
B. A 32-year-old client who had a total vaginal hysterectomy last year. A total hysterectomy (removal of the uterus and cervix) for non-cancerous reasons generally means that Pap tests are no longer necessary. However, if the hysterectomy was due to cervical cancer, continued screening might be needed.
C. A 47-year-old client who had a negative combined Pap and HPV test 5 years ago. For clients 30-65 years old, Pap tests can be done every 3 years OR combined Pap and HPV (co-testing) every 5 years. Since this client had a negative co-test 5 years ago, they are due for screening now, but they would not have been referred earlier.
D. A 15-year-old client who recently completed the vaccine series for human papillomavirus (HPV). The HPV vaccine does not replace the need for Pap tests but helps reduce the risk of cervical cancer. Routine Pap testing does NOT begin before age 21, so this client does not yet need screening.

A. "Remove clocks from the client's room." B. "Check on the client frequently while he is in the restroom." C. "Encourage physical activity throughout the day to expend energy." D. "Use full-length side rails on the client's bed."

Correct Answer is C

Explanation

A. "Remove clocks from the client's room." –
Removing clocks can increase confusion and disorientation. Instead, having a visible clock and calendar can help the client stay oriented.
B. "Check on the client frequently while he is in the restroom." –
While frequent monitoring is important, excessive surveillance may increase agitation and distress. A better alternative is to ensure the restroom is safe and accessible.
C. "Encourage physical activity throughout the day to expend energy." –
Engaging the client in physical activity helps reduce restlessness, promotes better sleep, and decreases the likelihood of agitation, which can reduce the need for restraints.
D. "Use full-length side rails on the client's bed." –
Full-length side rails can be considered a form of restraint as they may limit movement and increase the risk of falls or injury if the client tries to climb over them.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the records of several clients to determine cervical cancer screening recommendations. Which of the following clients should the nurse refer for a Papanicolaou (Pap) test?

Correct Answer is A

Explanation

A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who recently lost a loved one. The client reports frequent headaches, indigestion, and heart palpitations. Which of the following types of grief is the client likely experiencing?

A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take?

A charge nurse has reviewed fire safety procedures with staff members. Which of the following statements by a staff member indicates an understanding of the last action they should take?

A nurse is teaching a client who is immunocompromised and requires a protective environment. Which of the following statements should the nurse make?

A nurse is preparing to obtain a health history from a newly admitted client. Which of the following information should the nurse expect to include?

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates client advocacy?

A nurse is teaching a client about fire safety at home. Which of the following information should the nurse include in the teaching?

A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)