Exhibits

The nurse reviews the orders and plans initial steps for caring for the client.

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Inspect the bandage for drainage

Perform range of motion.

Administer ondansetron 4 mg IV.

Provide morphine 2 mg IV.

Check capillary refill on bilateral upper extremities

Palpate and compare radial pulses.

Answer and Explanation

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

Inspect the bandage for drainage: This is a standard post-injury assessment to monitor for excessive bleeding or other complications.

Perform range of motion: Range of motion exercises are contraindicated in cases of fractures, as movement could worsen the injury.

Administer ondansetron 4 mg IV: Ondansetron is an antiemetic that can help relieve the nausea the client is experiencing.

Provide morphine 2 mg IV: Morphine is indicated for pain management, especially since the client is experiencing significant pain.

Check capillary refill on bilateral upper extremities: This is important to assess circulation and ensure there is no vascular compromise.

Palpate and compare radial pulses: This assesses circulation and can help identify any vascular injury or compromise due to the humeral fracture.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Fluid resuscitation due to capillary leaking is the primary goal when administering crystalloid fluids after burns. Severe burns lead to increased capillary permeability, causing fluid to leak into the interstitial space and necessitating resuscitation to restore intravascular volume.

B. While extension of plasma volume is a consideration, the primary focus in burn management is addressing fluid resuscitation to compensate for fluid loss from capillary leakage rather than simply waiting for blood products.

C. Replacement of insensible water loss occurs, but it is not the main physiological response targeted with crystalloid fluid administration in the acute phase after significant burns.

D. Restoration of electrolyte balance is important, but the immediate concern following a burn is fluid resuscitation to maintain adequate circulation and prevent shock.

A. Maintain strict intake and output. B. Keep head of bed raised 45 degrees. C. Assess warmth of extremities. D. Monitor blood glucose level.

Correct Answer is A

Explanation

A. Maintaining strict intake and output is crucial in managing septic shock, as it helps assess kidney function and fluid balance, which are vital in this critical condition.

B. Keeping the head of bed raised can help with respiratory function, but it is not the primary focus in septic shock management.

C. Assessing warmth of extremities is important but does not provide immediate information about the client’s hemodynamic status.

D. Monitoring blood glucose levels is important for overall care, especially if the patient is receiving insulin or has diabetes, but it is not the most critical intervention in the context of septic shock.

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Exhibits The nurse reviews the orders and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and orders. Click to mark whether the assessment finding represents a therapeutic result of the furosemide administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.)

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Exhibits

The nurse reviews the orders and plans initial steps for caring for the client.

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.