br>History and Physical

BP 100/60 mm Hg Pulse 52/min
Respiratory rate 20/min

Temperature 37.2" C (99.0° F)

A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the

client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer furosemide.

Withhold digoxin.

Withhold spironolactone.

Administer ferrous sulfate.

Answer and Explanation

The Correct Answer is B

A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.

B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.

C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.

D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.

B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.

C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.

D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.

A. Varicella-zoster B. Vancomycin-resistant enterococcus (VRE) C. Pertussis D. Rotavirus

Correct Answer is C

Explanation

A. Varicella-zoster (chickenpox) requires airborne precautions due to its transmission via respiratory droplets or aerosols.

B. Vancomycin-resistant enterococcus (VRE) is typically transmitted through direct contact with contaminated surfaces or equipment and does not require droplet precautions.

C. Pertussis (whooping cough) is transmitted via respiratory droplets and requires droplet precautions to prevent transmission to others.

D. Rotavirus is primarily transmitted through the fecal-oral route and requires contact precautions, not droplet precautions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first?

Correct Answer is D

Explanation

A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

Correct Answer is C

Explanation

A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment?

A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take?

A home health nurse is reviewing treatment goals with a client who has diabetes mellitus.The nurse should evaluate which of the following laboratory tests to determine effective long- term management of blood glucose levels?

A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make?

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching?

A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?