A nurse on a medical unit is admitting a client.

Exhibits

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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.

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. A client who has a history of pancreatitis and reports severe abdominal pain B. A client who has heart failure and reports severe dyspnea C. A client who is scheduled for abdominal surgery in 1 hr D. A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL

Correct Answer is B

Explanation

A. While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B. Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C. While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D. While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.

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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

After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's siblings should the nurse expect?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?

A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For which of the following results should the nurse notify the provider?

A nurse is preparing to admit a client who has bacterial meningitis. Which of the following items should the nurse place in the client's room?

A nurse is preparing to administer medication to a child through an enteral tube. Which of the following actions should the nurse take after administering the medication?

A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal series with fluoroscopy. Which of the following information should the nurse provide?