Exhibits here

The nurse is implementing the plan of care.

For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.

Answer and Explanation

The Correct Answer is []

Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.

Cardiovascular

Monitor vital signs continuously

The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.

Provide warmth

Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.

Respiratory

Assess lung sounds

The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.

Chest x-ray

Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.

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

Explanation

- A) Knowing the medications the patient takes is crucial for understanding her medical history and any potential interactions with treatments that may be administered.

- B) Understanding the events leading up to the fall can help in assessing the cause and potential injuries sustained, which is important for her current and future treatment plans.

- C) Information about the last meal is important for anesthesia considerations, in case surgery is required, and for understanding the patient's nutritional status.
- D) Knowing if the patient is pregnant is vital as it influences the management of her care and the urgency of certain tests, as well as the avoidance of potential harm to the fetus.
- E) Information about cohabitants can be useful for social support and may also provide additional information about the circumstances leading to the injury.
- F) While insurance status is a practical consideration, it is not clinically relevant to the secondary survey and immediate care of the patient. Therefore, it is not an appropriate question at this stage.

A. Listen attentively to the client's description of the event. B. Report the incident to the university's security department. C. Do not allow client to shower until all evidence is obtained. D. Determine the client's personal reaction to the reported rape.

Correct Answer is C

Explanation

A. Listen attentively to the client's description of the event. While important for providing emotional support, it is secondary to preserving forensic evidence.
B. Report the incident to the university's security department. This is necessary but not as immediately critical as preserving evidence.
C. Do not allow client to shower until all evidence is obtained. Preserving evidence is the highest priority in this situation to ensure a thorough forensic investigation and legal process.
D. Determine the client's personal reaction to the reported rape. Understanding the client's emotional state is important for providing support, but it should be done after ensuring that critical forensic evidence is collected.

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Naxlex Comprehensive Predictor Exams

Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

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

Explanation

The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the CLIENT?

Exhibits 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.

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

Exhibits 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.