nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

"Please ring for assistance when you wish to get out of bed."

"We will have to get a prescription from your provider."

"Yes, you are free to move around as you wish."

"No, you are on strict bedrest and must not be up."

Answer and Explanation

The Correct Answer is A

A. Clients with Ménière's disease may experience dizziness and balance issues, so it is important to ensure safety by asking them to ring for assistance when moving around to prevent falls or injuries.
B. A prescription from the provider is not typically required for ambulation; instead, safety measures should be in place.
C. Allowing free movement without assistance may increase the risk of falls due to balance problems associated with Ménière's disease.
D. Strict bedrest is generally not necessary unless specifically indicated by the provider; assistance and safety measures are more appropriate.

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Correct Answer is ["A","B","C","F"]

Explanation

A. Urine output: A decrease in urine output from 480 mL/8 hr to 320 mL/8 hr indicates reduced renal perfusion or worsening heart failure. This finding suggests potential fluid retention or impaired kidney function, requiring further investigation and action.

B. Oxygen saturation: A drop in oxygen saturation from 95% to 88% indicates worsening oxygenation and potential respiratory distress or fluid overload. This finding necessitates further assessment and possible intervention to manage the client's respiratory status.

C. Weight: An increase in weight from 80 kg to 82.1 kg suggests fluid retention, which is common in heart failure. This weight gain indicates worsening fluid balance and may require adjustment in treatment to address fluid overload.

F. Breath sounds: The presence of scattered crackles on Day 4 suggests pulmonary congestion or fluid accumulation, which is concerning in heart failure. This finding indicates a worsening of the client’s condition and requires further evaluation and management.

Explanation of Incorrect Options:

D. Temperature: The temperature has slightly decreased but is still within a normal range. This finding does not require immediate further action.

E. Blood pressure: Although there is a change in blood pressure from 108/50 mm Hg to 138/80 mm Hg, this increase is not as critical as the other findings. It is important but less urgent in this context compared to the issues with oxygen saturation, urine output, weight, and breath sounds.

A. Assistive personnel B. Oncology nurse C. Phlebotomist D. Senior nursing student

Correct Answer is B

Explanation

A. Assistive personnel typically do not have the training or authority to perform the critical double-check of blood products.
B. An oncology nurse is a qualified staff member who has the necessary training and experience to correctly verify blood labels and client ID bracelets before transfusion.
C. A phlebotomist is trained in blood collection but is not generally authorized to perform blood transfusion verifications.
D. A senior nursing student may not have the required certification or experience to safely double-check blood transfusion products.

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nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure. Exhibits A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action? (Select all that apply.)

Correct Answer is ["A","B","C","F"]

Explanation

A nurse is selecting a qualified staff member to double-check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified?

Correct Answer is B

Explanation

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