Exhibits

A nurse is collecting data from a client who has pneumonia and a prescription for cefazolin. Which of the following findings should the nurse report to the provider prior to administering the initial dose? (Cliick on the exhibit tabs for additional information about t three tabs that contain separate categories of data.)

Temperature

WBC count

Allergies

Chest x-ray

Answer and Explanation

The Correct Answer is C

Rationale:

• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.

• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.

• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.

• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. "I should use a firm mattress in my baby's crib.": A firm mattress reduces the risk of sudden infant death syndrome (SIDS) and suffocation by providing a stable, flat surface for safe infant sleep. This is a key recommendation in safe sleep guidelines.

B. "I should set my hot water heater at 130 degrees Fahrenheit.": Setting the water heater at 130°F increases the risk of scald burns, especially for infants and young children. The recommended temperature to prevent burns is 120°F or lower.

C. “I should use a crib with side rails that drop": Drop-side cribs have been banned due to safety concerns, including risk of entrapment and suffocation. Using a crib with fixed side rails is safer and recommended.

D. "I should position my baby on their stomach to sleep during the day.": Placing infants on their stomach to sleep increases the risk of SIDS. The safest position for sleep is on the back, both during the day and night.

A. "The client in room 205 has had several visitors today." B. "The client in room 204 received some pain medicine earlier today." C. "The client in room 205 is scheduled for a dressing change at 1800 D. "The client in room 203 will undergo surgery at 0900 tomorrow." E. "The client in room 204 has a new prescription for IV gentamicin”

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

Explanation

Rationale:

A. "The client in room 205 has had several visitors today." This is non-essential social information that does not contribute to continuity of care or clinical decision-making. Change-of-shift reports should focus on relevant clinical updates and care plans.

B. "The client in room 204 received some pain medicine earlier today." This statement lacks specificity, such as the type, dosage, time, and client response to the medication. Without detailed clinical context, the information is not useful for ensuring safe, consistent care.

C. "The client in room 205 is scheduled for a dressing change at 1800." This provides specific, actionable information that the oncoming nurse needs to know in order to follow the treatment plan and ensure timely wound care.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." This is essential procedural information that allows the next nurse to prepare the client appropriately and monitor for any pre-op needs, such as NPO status or lab work.

E. "The client in room 204 has a new prescription for IV gentamicin." This communicates a significant change in the client’s medication regimen, which may require monitoring for side effects, such as nephrotoxicity or ototoxicity, making it critical to include in report.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

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

Explanation

A nurse is caring for a client who is to undergo a subtotal thyroidectomy. Which of the following items should the nurse place at the client’s bedside?

A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is preparing to insert a nasogastric tube in a client. Which of the following actions should the nurse take?

A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

A nurse is preparing to administer an antibiotic to a client who has pneumonia. After confirming that the client's assigned identification number matches the medication administration record, the nurse should use which of the following as a second identifier?

The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

A nurse is assisting with the care of a client in a PACU. Exhibits Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.