A nurse on a medical unit is admitting a client.
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Nurses' Notes
Day 1, 1600:
Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."
States they are not able to sleep well on their back at night because of difficulty breathing.
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.
Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining 10 pounds in the past month.
Reports history of type 2 diabetes mellitus and hypertension.
Heart rate 130/min
ECG monitor showing sinus tachycardia
edema
Breathing rapid and shallow. Crackles
gaining 10 pounds in the past month.
The Correct Answer is ["A","B","C","D","E"]
Correct answers:
Nurses Notes Day 1, 1600:
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 150/min, ECG monitor showing sinus tachycardia, 5, auscultated. Lower extremity edema noted, 2+ bilaterally. Radial and pedal pulses 1 bilaterally. Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining "10 pounds in the past month."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Asking the client to help with the dressing change may not be appropriate, especially if the client is frail or recovering from surgery. Older adults may have limited mobility or strength, and they may require assistance rather than being asked to participate actively.
B. Waiting for the client to approach the nurse for assistance may not be conducive to providing optimal care. Nurses should proactively assess the client's needs and offer assistance as appropriate, especially in the postoperative period when mobility may be limited.
C. Using paper tape for securing the new dressing is a good choice because older adults may have delicate skin that is prone to tearing or irritation. Paper tape is gentle on the skin and less likely to cause damage or discomfort compared to other types of adhesive dressings.
D. Applying the dressing loosely over the incision may compromise its effectiveness in providing wound protection and promoting healing. Dressings should be applied securely but not too tightly to avoid restricting circulation or causing discomfort.
Correct Answer is A
Explanation
A. Correct. Ampicillin is a penicillin antibiotic and is contraindicated in clients who are allergic to penicillin.
B. Incorrect. Erythromycin is not a penicillin antibiotic and can be an alternative for clients allergic to penicillin.
C. Incorrect. Cefazolin is a cephalosporin antibiotic and is not related to penicillin. It can be used as an alternative in clients allergic to penicillin.
D. Incorrect. Clindamycin is not related to penicillin and can be used as an alternative in clients allergic to penicillin.
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