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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is []

Explanation

Hypocalcemia:

- Condition: Hypocalcemia is a condition characterized by low levels of calcium in the blood. In newborns and infants, this can occur due to inadequate intake or absorption of calcium, and it can manifest as seizures.

- Rationale: The infant was fed cow's milk, which is not recommended for infants under one year old and can interfere with calcium absorption, possibly leading to hypocalcemia. Seizures can be a symptom of severe hypocalcemia.

Actions to Take:

1. Administer oral calcium:

- Rationale: Direct administration of calcium helps to quickly elevate calcium levels in the blood, addressing the immediate cause of the seizures.
2. Educate the mother on nutrition needs:

- Rationale: It's important to educate the mother on the appropriate nutritional needs for an

infant, emphasizing the importance of breastfeeding or formula feeding instead of cow's milk, to prevent recurrence.

Parameters to Monitor:

1. Electrocardiogram:

- Rationale: Monitoring the ECG is crucial as hypocalcemia can cause cardiac arrhythmias, and the ECG can provide real-time information about the infant's cardiac status.
2. Oxygen saturation:

- Rationale: Monitoring oxygen saturation ensures that the infant maintains adequate oxygenation, especially after a seizure and during recovery, to detect any respiratory complications early.

A. Fluid volume deficit. B. Bowel incontinence. C. Caregiver role strain. D. Impaired bed mobility.

Correct Answer is A

Explanation

A. Fluid volume deficit. Gastroenteritis, characterized by fever, chills, anorexia, and diarrhea, can lead to significant fluid loss, especially in an older adult who may already have compromised fluid balance due to other factors such as stroke-related immobility. Fluid volume deficit is a critical problem that requires immediate attention to prevent complications such as hypovolemic shock.
B. Bowel incontinence. While bowel incontinence is a concern, it is not as immediately life- threatening as fluid volume deficit.
C. Caregiver role strain. While important for the client's overall well-being, caregiver role strain is a secondary concern compared to the client's physiological needs.
D. Impaired bed mobility. Impaired bed mobility is a long-term issue that requires attention but is not as urgent as addressing the immediate physiological needs of fluid volume deficit.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is []

Explanation

Correct Answer is A

Explanation

Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?

Which laboratory test results should the nurse monitor in a client who has end-stage renal disease (ESRD)?

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

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?