Exhibits

Review H and P, nurse's note, flow sheet, and orders.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential condition
Opioid-induced constipation

The client’s report of no bowel movement since surgery, along with the use of morphine for pain management, suggests opioid-induced constipation. Opioids are known to slow down gastrointestinal motility.

Actions to Take:

Administer a stool softener

Stool softeners can help ease bowel movements by softening the stool, which is a common intervention for constipation, particularly opioid-induced.

Ask the client about ambulation

Encouraging ambulation is an effective way to stimulate gastrointestinal motility and reduce the risk of constipation.

Parameters to Monitor:

Fluid intake

Adequate hydration is crucial for maintaining proper bowel function, especially when using stool softeners or other constipation treatments.

Intraabdominal pressure

Monitoring intraabdominal pressure can help assess for severe constipation or potential complications, such as bowel obstruction.

Nursing Test Bank

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Correct Answer is B

Explanation

A. While applying povidone to the site is important for aseptic technique, it does not address the immediate concern regarding the use of the luer-lock syringe for irrigation.

B. Directing the nurse to attach the luer-lock tip to the irrigation port is the correct action, as luer-lock syringes are designed to provide a secure connection, preventing accidental disconnection during the irrigation process.

C. Sending an unlicensed assistive personnel to gather equipment is unnecessary if the new nurse already has the required equipment.

D. Using water with 5% dextrose (DW) is not appropriate for irrigating an intravenous catheter; normal saline is the preferred solution.

A. Discuss aggressive respiratory treatment options B. Obtain a sputum culture C. Monitor the oxygen saturation D. Allow the client to take a position of comfort E. Wean the supplemental oxygen F. Prepare for deep tracheal suctioning G. Consider positive pressure ventilation H. Discuss with the client potential asthma triggers

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

Explanation

A. While discussing treatment options is important, it may not be immediately necessary at this point unless the client shows signs of severe respiratory distress or failure.

B. Given the client's respiratory distress and recent cold symptoms, obtaining a sputum culture can help identify any underlying infection, which is important for appropriate treatment, particularly with the prescribed azithromycin.

C. Continuous monitoring of oxygen saturation is essential to ensure that the client's oxygen levels are adequate, especially since she is at risk for hypoxia. The goal is to maintain oxygen saturation greater than 94%.

D. Positioning the client in a way that enhances her comfort, such as sitting upright, can help improve her breathing and reduce respiratory distress. This is a fundamental nursing intervention in respiratory care.

E. If the client's oxygen saturation improves, the nurse can begin to wean the supplemental oxygen while monitoring for any signs of respiratory distress. This step should be approached cautiously to ensure the client maintains adequate oxygen levels.

F. There is no indication that the client requires deep tracheal suctioning at this moment. This action is reserved for patients with excessive secretions or compromised airway patency.

G. Positive pressure ventilation would typically be considered if the client were in severe respiratory distress or failure. The current assessment does not indicate an immediate need for this intervention.

H. Education on potential asthma triggers is crucial for the client's long-term management. This discussion can help the client avoid situations that could lead to future exacerbations, thus improving her overall asthma control.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock-tipped syringe. Which action should the charge nurse take?

Correct Answer is B

Explanation

Exhibits The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

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

Explanation

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

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