Exhibits

A nurse is collecting data from a client following a thoracentesis. The nurse should notify the provider for which of the following findings? (Click on the "Exhibit" button for additional information about the client There are three tabs that contain separate categories of data.)

Respiratory rate

Blood pressure

Hematocrit

PCO2

Answer and Explanation

The Correct Answer is A

Choice A. Respiratory rate
Reason: After thoracentesis, it's crucial to monitor the patient's respiratory rate. An increased respiratory rate could indicate respiratory distress. In this case, the respiratory rate is 26/min, which is higher than the normal range (12-20 breaths per minute for an adult at rest). Therefore, the nurse should notify the provider about this finding.

Choice B. Blood pressure
Reason: The blood pressure of the patient is 110/76 mm Hg, which falls within the normal range (90/60 mm Hg to 120/80 mm Hg). Therefore, there is no need for the nurse to notify the provider about the patient's blood pressure.

Choice C. Hematocrit
Reason: The hematocrit level is 43%, which is within the normal range (38.8% to 50.0% for males, and 34.9% to 44.5% for females). Therefore, there is no need for the nurse to notify the provider about the patient's hematocrit level².

Choice D. PCO2
Reason: The PCO2 level is 37 mm Hg, which is within the normal range (35 to 45 mm Hg). Therefore, there is no need for the nurse to notify the provider about the patient's PCO2 level.

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Correct Answer is C

Explanation

Choice A reason: Moving the overbed table away from the bed may reduce clutter but does not directly prevent falls for a client with dementia.

Choice B reason: Leaving the television on may provide comfort or distraction, but it does not prevent falls and could potentially contribute to disorientation.

Choice C reason: Applying a motion sensor mat alerts staff when the client attempts to get out of bed, which can help prevent falls in a client with dementia.

Choice D reason: Raising all four side rails is considered a form of restraint and could increase the risk of injury if the client attempts to climb over them.

A. Pull the fire alarm panel. B. Remove the client from the room. C. Close the door to the client's room. D. Obtain a fire extinguisher.

Correct Answer is B

Explanation

Choice A reason: While pulling the fire alarm is important, the immediate priority is the safety of the client.

Choice B reason: The nurse's first action should be to remove the client from the room to ensure their safety from the potential fire.

Choice C reason: Closing the door may help contain smoke and fire, but it is not the first action to take before ensuring the client's safety.

Choice D reason: Obtaining a fire extinguisher is important after the client is safe and the alarm has been pulled to alert others.

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Exhibits A nurse is collecting data from a client following a thoracentesis. The nurse should notify the provider for which of the following findings? (Click on the "Exhibit" button for additional information about the client There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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Exhibits

A nurse is collecting data from a client following a thoracentesis. The nurse should notify the provider for which of the following findings? (Click on the "Exhibit" button for additional information about the client There are three tabs that contain separate categories of data.)