Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow-up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep at night.
Which intervention is most important for the nurse to implement?

Ask the spouse if the client seems to be depressed.

Tell the spouse to wait outside so the client can be assessed for depression.

Explain that depression often occurs after a life-threatening experience.

Encourage the client to further describe his feelings.

Answer and Explanation

The Correct Answer is D

A.   Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B.   While privacy is important, the spouse can often provide additional valuable information.
C.   Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D.   Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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Correct Answer is C

Explanation

A. Suggesting the antecubital site does not address the immediate issue of using an inappropriate needle size.
B. Sending a UAP to gather equipment is not an immediate action needed to correct the mistake.
C. Using an 18-gauge needle to irrigate an IV catheter is inappropriate and could damage the catheter. The charge nurse should instruct the new nurse to remove the needle and use a syringe without a needle to perform the irrigation safely.
D. Starting a secondary infusion is unrelated to the irrigation process and does not correct the inappropriate needle use.

A. Monitor the amount of drainage from the client's incision. B. Observe both lower extremities for redness and swelling. C. Evaluate the client's ability to use an incentive spirometer. D. Palpate all peripheral pulse points for volume and strength.

Correct Answer is B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

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Naxlex Comprehensive Predictor Exams

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

Correct Answer is C

Explanation

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

A client receives a prescription for acetaminophen 1,000 mg PO every 8 hours PRN for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?