Exhibits

The nurse is planning care for the client.

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 []

Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.

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Correct Answer is B

Explanation

A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.

A. Stop suctioning until the pulse oximeter reading is above 95%. B. Reposition the pulse oximeter clip to obtain a new reading. C. Complete the intermittent suction of the nasopharynx. D. Apply an oxygen mask over the client's nose and mouth.

Correct Answer is B

Explanation

A. Stopping suctioning may not be necessary if the oxygen saturation is stable and within acceptable limits. The key is to ensure that the suctioning procedure is not adversely affecting oxygenation.
B. Repositioning the pulse oximeter clip is a good practice to ensure accurate readings, especially if there is any concern about the reliability of the current measurement. An accurate oxygen saturation reading is essential for assessing the impact of the suctioning procedure.
C. Completing the suctioning procedure may be appropriate if the oxygen saturation is stable. However, it’s important to ensure that the oxygen saturation readings are accurate and reliable before continuing.
D. Applying an oxygen mask may be necessary if the client's oxygen saturation drops, but there is no indication that the oxygen saturation has decreased. Repositioning the oximeter clip is a more immediate step to ensure accurate readings.

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Naxlex Comprehensive Predictor Exams

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

Correct Answer is B

Explanation

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

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.

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