Exhibits

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.

The client reports he was able to sleep through the night

The left arm is warm to touch. The client's left shoulder and collarbone are symmetric

The client reports mild nausea and has no desire to eat breakfast

Answer and Explanation

The Correct Answer is ["A","B"]

The client reports he was able to sleep through the night: This indicates pain management may be effective, allowing the client to rest, which is a positive sign of progress.

The left arm is warm to touch: This suggests good circulation in the injured limb, which is crucial for healing.

The client’s left shoulder and collarbone are symmetric: Symmetry suggests that the alignment of the shoulder and collarbone is stable, which indicates no further dislocation or misalignment post-injury.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Noting the presence of an auscultatory gap is essential, as it may indicate that the blood pressure reading could be inaccurately low if not recognized. This helps ensure the accuracy of the blood pressure measurement.

B. Repositioning the stethoscope may be necessary if the sounds are unclear, but recognizing the potential auscultatory gap should be prioritized first.

C. Re-inflating the cuff may be appropriate if the nurse is unsure about the readings; however, identifying an auscultatory gap is the first step to ensure accurate assessment.

D. Continuing with the blood pressure assessment without acknowledging the silence followed by a Korotkoff sound may lead to misinterpretation of the blood pressure readings.

A. Explain that the client may need medication therapy. B. Encourage the client to reduce consumption of fatty foods. C. Confirm that this value is helpful in reducing cardiac risk. D. Ask the client about hereditary cardiac risk factors.

Correct Answer is C

Explanation

A. A high HDL level typically indicates a lower risk for heart disease, and medication therapy is generally not indicated for high HDL.

B. Reducing fatty food intake is not necessary since a high HDL level is associated with lower cardiovascular risk.

C. Confirming that a high HDL level is beneficial for reducing cardiac risk is important, as it reflects a protective factor against heart disease.

D. While asking about hereditary cardiac risk factors is relevant in a comprehensive assessment, it is not immediately necessary in response to a high HDL level.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is A

Explanation

A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

Correct Answer is C

Explanation

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress?

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAPY?

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Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?