A nurse on a medical unit is admitting a client.

Exhibits

Click to highlight the findings that should be reported to the provider. To deselect a finding, click on the finding again.

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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Fatigue is a common symptom of anemia, which can result from a low hemoglobin level.
Decreased oxygen-carrying capacity leads to feelings of tiredness.
B. Thickened fingernails are not typically associated with low hemoglobin levels. This symptom is more commonly seen in conditions such as fungal infections or psoriasis.
C. The need to go to the bathroom frequently is not directly related to low hemoglobin levels. It may be indicative of other conditions such as urinary tract infections or diabetes.
D. Shaky hands are not typically associated with low hemoglobin levels. This symptom may be seen in conditions such as essential tremor or Parkinson's disease.

A. Turn the newborn's head quickly to one side while they are sleeping. B. Place a finger in the newborn's palm. C. Clap hands after laying the newborn on a flat surface. D. Hold the newborn upright with one foot touching the crib surface E. None F. None

Correct Answer is C

Explanation

A. Turn the newborn's head quickly to one side while they are sleeping: This action does not elicit the Moro reflex. The Moro reflex is a response to a sudden loss of support, not a head-turning motion.

B. Place a finger in the newborn's palm: This action would elicit the palmar grasp reflex, not the Moro reflex.

C. Clap hands after laying the newborn on a flat surface: The Moro reflex is triggered by a sudden, loud noise or movement, such as clapping hands. This response causes the newborn to extend and then quickly flex the arms, a characteristic sign of the reflex.

D. Hold the newborn upright with one foot touching the crib surface: This action is not related to the Moro reflex. The stepping reflex is elicited by holding the newborn upright with their feet touching a surface, not the Moro reflex.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client whose Hgb is 8.8 mg/dL. Which of the following statements should the nurse expect?

Correct Answer is A

Explanation

A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new prescription for furosemide and asks the nurse about the purpose of the medication. The nurse states, "This medication is a diuretic that removes excess fluid from your body." Which of the following ethical concepts is the nurse exhibiting?

A nurse is reinforcing teaching about complete and Incomplete proteins with a client who has a prescription for a high-protein diet. The nurse should identify which of the following foods as sources of complete proteins? (Select all that apply.)

A nurse is contributing to the plan of care for a client who has bulimia nervosa. Which of the following interventions should the nurse recommend?

A nurse is collecting data from a client who is postoperative and received hydromorphone 4 mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of the following actions should the nurse take first?

A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of the following techniques should the nurse plan use to assist with time management?

A nurse in the emergency department is assisting with the care of a client. Exhibits For each assessment finding below, click to specify if the finding is consistent with appendicitis, diverticulitis, or celiac disease. Each finding may support more than 1 disease process.

A nurse is preparing a client's insulin regimen. Which of the following Insulins can be mixed? (Select all that apply.)