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Exhibits

Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.

Give ibuprofen 400 mg PO every 6 hours PRN for fever

Give 1,000 mL sodium chloride now

Discontinue the peripheral IV

Insert an indwelling urinary catheter

Apply cardiac telemetry monitoring

Collect blood to test electrolyte levels

Prepare to defibrillate the client

Collect blood for a type and screen

Answer and Explanation

Correct Answer : A,E,F

A. Give ibuprofen 400 mg PO every 6 hours PRN for fever
The client has a fever of 101.5° F (38.6° C), so administering ibuprofen to manage the fever is appropriate.
B. Give 1,000 mL sodium chloride now
This prescription is already ordered and being administered, so it does not need to be requested again.
C. Discontinue the peripheral IV
The client needs IV access for fluid administration and potential medications, so discontinuing the peripheral IV is not appropriate.
D. Insert an indwelling urinary catheter
There is no indication of urinary retention or need for precise fluid measurement, making this intervention unnecessary at this time.
E. Apply cardiac telemetry monitoring
Given the client's elevated heart rate and respiratory rate, cardiac telemetry monitoring would help in continuously assessing the client's cardiac status.
F. Collect blood to test electrolyte levels
Due to the client's symptoms and history of decreased fluid intake, electrolyte imbalance is a concern, and testing electrolyte levels is necessary.
G. Prepare to defibrillate the client
There is no indication of a cardiac emergency that would require defibrillation.
H. Collect blood for a type and screen
There is no indication of the need for a blood transfusion, making this intervention unnecessary.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Acceleration refers to a temporary increase in the fetal heart rate of at least 15 beats per minute above the baseline for at least 10 seconds. The observation of the fetal heart rate increasing 15 beats above baseline twice during the test indicates that accelerations are present, which is a reassuring sign of fetal well-being.
B. A nonreactive pattern would indicate that the test did not meet the criteria for accelerations or fetal heart rate reactivity, which is not the case here as the fetal heart rate did exhibit accelerations.
C. Fetal movement could contribute to accelerations but is not the term used to describe the findings of the test itself. The specific observation made was an increase in fetal heart rate, which is classified as an acceleration.
D. A positive tracing indicates that the nonstress test met criteria for fetal well-being, typically with at least two accelerations, but the correct term for the specific observation here is acceleration rather than describing the overall result.

A. What are the voices uttering? B. When are the voices most disturbing? C. How does the client cope with the voices? D. Which medication works best?

Correct Answer is A

Explanation

A. Understanding what the voices are saying is the most important initial step in assessing auditory hallucinations. This information helps the PN gauge the content of the hallucinations, which is crucial for developing a treatment plan and determining the level of risk to the client or others.
B. While knowing when the voices are most disturbing provides useful information for managing symptoms, it is less critical than understanding the content of the hallucinations for developing an initial treatment plan.
C. Assessing how the client copes with the voices is important for ongoing management but comes after understanding what the voices are saying. Coping strategies can be developed based on the nature of the hallucinations.
D. Determining which medication works best is not an immediate priority during the initial assessment. Medication effectiveness will be evaluated over time rather than being a primary focus during the first report of hallucinations.

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Exhibits Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?

Correct Answer is A

Explanation

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?

Correct Answer is A

Explanation

The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location? (Select the correct location on the image)

The practical nurse (PN) is observing a newly hired unlicensed assistive personnel (UAP) bathing a client who has type 2 diabetes mellitus (DM). The UAP places the client's feet in a wash basin filled with warm soapy water to soak. Which action should the PN take?

The practical nurse (PN) is assigned to provide care for a client with rheumatoid arthritis who is preparing for discharge. While planning the client's care, the PN should identify which client goal as the most important?

While the practical nurse (PN) and unlicensed assistive personnel (UAP) are turning a client with an abdominal incision, the client's incision eviscerates. Which task is best for the PN to assign to the UAP?

A client receives a prescription for digoxin 0.25 mg by mouth. The medication is available in 0.125 mg tablets. How many tablets should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

Exhibits

Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.