Exhibits

The nurse performs an initial focused assessment of the client.

Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

Blood pressure 130/86 mm Hg

Temperature 98.9" F (37.1° C)

Oxygen saturation 88% on room air

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"}}

Blood pressure 130/86 mm Hg
- Neither Disease Process Nor Medication: This blood pressure reading is within the normal range for an adult and does not indicate a specific disease process or medication effect.
Temperature 98.9° F (37.1° C)
- Neither Disease Process Nor Medication: This temperature is within the normal range and does not indicate a specific disease process or medication effect.
Oxygen saturation 88% on room air
- Disease Process: This low oxygen saturation level is likely due to the acute asthma attack, which is a disease process affecting the client's ability to oxygenate properly.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Clear, dark amber-colored urine may indicate dehydration or concentrated urine, which does not necessarily signify improvement in liver function or treatment efficacy.

B. A prothrombin time within normal limits may indicate improved liver function; however, it is not the primary goal of the treatment plan focused on managing ascites and fluid retention in cirrhosis.

C. Decreased abdominal girth is a key indicator of progress in managing fluid retention associated with cirrhosis, as the treatment plan aims to reduce ascites through a low sodium diet and albumin infusions.

D. Improved level of consciousness is essential for overall recovery but is not the primary measure of progress related to fluid management and treatment effects in this context.

A. Assess the pulses proximal to the fracture site. B. Assess the pin sites for signs of infection. C. Administer pain medication at designated intervals around the clock. D. Remove traction every shift and provide skin care.

Correct Answer is A

Explanation

A. Assessing the pulses proximal to the fracture site is crucial for evaluating blood circulation to the affected limb and detecting potential complications such as compartment syndrome.

B. While monitoring pin sites for signs of infection is important, the priority is ensuring adequate circulation.

C. Administering pain medication is essential for comfort but does not address potential complications from skeletal traction.

D. Removing traction every shift is not advisable as it can compromise the alignment and healing of the fracture.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

Correct Answer is C

Explanation

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

Correct Answer is A

Explanation

Exhibits The nurse is reviewing the client's dietary choices for opportunities to promote better outcomes by limiting gout attacks. Select the 3 dietary choices that are not part of the recommended diet for a client with gout.

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?