A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

ineffective gas exchange.

ineffective breathing pattern

activity intolerance.

decreased cardiac function

Answer and Explanation

The Correct Answer is B

Choice A rationale: Ineffective gas exchange is related to respiratory issues but may not be the priority in this case.

Choice B rationale: Ineffective breathing pattern is the priority problem, as evidenced by shallow respirations and reluctance to perform coughing and deep breathing, which can lead to respiratory complications.

Choice C rationale: Activity intolerance is not the priority problem based on the given data.

Choice D rationale: Decreased cardiac function is not the priority problem based on the given data.

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Correct Answer is C

Explanation

Choice A rationale: The deltoid muscle may not accommodate larger volumes as comfortably as other sites.

Choice B rationale: The dorsogluteal site is not recommended due to the risk of injury to the sciatic nerve.

Choice C rationale: The ventrogluteal site is the preferred site for IM injections in adults, providing a safe and well-vascularized muscle.

Choice D rationale: The vastus lateralis is a suitable site for infants and young children but may not be the most comfortable for adults receiving a 2 mL injection.

A. Encourage eating potassium-rich foods. B. Restrict sodium in the diet C. Decrease water intake D. Monitor vital signs E. Monitor intake and output.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale: Hypernatremia involves elevated sodium levels, so encouraging potassium-rich foods is not directly related to addressing hypernatremia.

Choice B rationale: Restricting sodium in the diet is appropriate to help manage and reduce hypernatremia. This can prevent further complications of hypernatremia, such as dehydration, confusion, seizures, and coma.

Choice C rationale: This is not an appropriate intervention for hypernatremia, as water intake can help dilute the sodium levels and restore the fluid balance in the body.

Decreasing water intake can worsen the hypernatremia and cause dehydration. Choice D rationale: This is an appropriate intervention for hypernatremia, as high sodium levels can affect the fluid balance and blood pressure in the body. Monitoring

vital signs can help detect any changes or abnormalities that may indicate worsening of the condition or need for further treatment.

Choice E rationale: Monitoring intake and output helps assess fluid balance and response to interventions for hypernatremia.

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A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is to administer a volume of 2 mL intramuscularly (IM) to a 150-pound client. Assuming that there are no skin problems, which is the preferred site for the injection?

Correct Answer is C

Explanation

A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?

In order to minimize discomfort when giving an injection to a client, the nurse should:

A nurse is caring for a client who has a diagnosis of alcohol withdrawal. Which serum laboratory value validates the client's admitting diagnosis? A serum:

A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

A nurse is admitting a patient who has a DTI (deep tissue injury) to the hospital. The nurse understands that a DTI:

The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

The nurse is transcribing a medication order and schedules dosing for 10:00 AM, 2:00 PM and 6:00 PM. Which medication order is consistent with this schedule?