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. Using an adhesive remover can help safely and effectively remove the adhesive residue from the skin without causing irritation or damage.
B. Scrubbing the skin around the colostomy can cause skin irritation and increase the risk of skin breakdown. Gentle cleaning with warm water and mild soap is recommended.
C. Most colostomy bags do not require suctioning of stool, as they are designed to collect fecal matter without the need for suctioning.
D. It is generally recommended to empty the colostomy bag when it is about one-third to one- half full to prevent leakage and maintain skin integrity.

A. Name and medical record number B. Birth date and mother's name C. Age and diagnosis D. Footprints and identification number

Correct Answer is A

Explanation

- Rationale for A: The name and medical record number are unique identifiers that are used to accurately match a newborn with their medical records and ensure that the correct medication is administered. This method of identification minimizes the risk of medical errors, which is crucial in a hospital setting where multiple newborns may be present.

- Rationale for B: While the birth date and mother's name are important, they may not be as effective for identification because multiple newborns could share a birth date, and there could be more than one mother with the same name in the maternity ward.

- Rationale for C: Age and diagnosis are not specific enough for the identification of a newborn when administering medication. Age is not a distinguishing factor in a neonatal unit, and the diagnosis could apply to multiple infants.

- Rationale for D: Footprints and identification number can be used as secondary identifiers. However, footprints may change rapidly as the newborn grows, and the identification number should be cross-referenced with the name and medical record number for accurate identification.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is preparing to administer medication to a newborn. Which of the following information should the nurse use to identify the newborn?

Correct Answer is A

Explanation

A nurse is assisting with triaging clients in a mass casualty situation. The nurse should recommend that which of the following clients receive care first?

A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

A nurse is reinforcing discharge teaching with the guardian of a client who is neutropenic. Which of the following instructions should the nurse include?

A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?

A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives?

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)

A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?