Exhibits

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

Complete thee 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 []

Small intestinal obstruction is indicated by the client’s abdominal distension, absence of bowel sounds, refusal to eat, and episodes of vomiting. The laboratory results show metabolic acidosis (HCO3 of 16 mEq), which can be associated with a bowel obstruction.
Placing a nasogastric tube helps decompress the stomach and relieve pressure caused by the obstruction, while giving IV fluids helps to prevent dehydration and electrolyte imbalances that can occur with vomiting and obstruction.
Monitoring signs and symptoms of dehydration is crucial as the client has been vomiting and may not be able to maintain adequate fluid intake. Monitoring temperature is also essential to detect any signs of infection or complications related to the obstruction.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Apply sterile foam dressing over wound bed is indicated because the dressing helps to keep the wound bed moist and protected.
Maintain clean medical asepsis is not indicated for wound care requiring sterile technique. Pressure wound care should maintain sterile technique to prevent infection.
Gather materials to change soiled items only is not indicated since all necessary supplies for the wound change should be prepared in advance.
Thoroughly clean wound using normal saline prior to redressing is indicated to remove debris and promote healing.
Apply sterile gloves prior to changing is indicated to ensure the wound area is not contaminated during dressing changes.
Place sterile gauze directly on wound bed is not indicated; a foam dressing is being used, not gauze.

A. Risk for aspiration related to difficulty swallowing. B. Chronic pain related to tissue destruction by tumor. C. Imbalanced nutrition less than body requirements. D. Anxiety and grieving related to progression of disease.

Correct Answer is A

Explanation

A. The priority nursing problem is the risk for aspiration related to difficulty swallowing (dysphagia). This condition poses an immediate risk to the client's safety as they may inhale food or liquids into the lungs, leading to aspiration pneumonia, which can be life-threatening.
B. While chronic pain is significant, addressing the risk of aspiration is more urgent in this context, especially considering the client's current symptoms.
C. Imbalanced nutrition is a concern, but it is secondary to the immediate risk posed by dysphagia and aspiration.
D. Although anxiety and grieving are important to address, they do not present an immediate threat to the client’s safety compared to the risk of aspiration.

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Naxlex Comprehensive Predictor Exams

Exhibits The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

Correct Answer is A

Explanation

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in, "500 mg per 100 mL of dextrose 5% in water." To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?