On the second postoperative day, a client who had a colon resection is starting to eat and ambulate with assistance. Although the client has a prescription for an oral analgesic, they request that the PCA containing morphine be continued for one more day due to fear of pain. Which intervention is most important for the nurse to implement?

Measure urinary output to ensure renal functioning.

Administer the oral analgesic medication an hour before discontinuing the PCA pump.

Monitor for a depressed respiratory rate.

Teach about the need to progress to a high-fiber diet.

Answer and Explanation

The Correct Answer is B

Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.

Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.

Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.

Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.

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Correct Answer is D

Explanation

Choice A reason: Encouraging the client to lie still during the assessment is not advisable as it does not provide an accurate representation of the client's functional abilities and needs during rehabilitation.

Choice B reason: While understanding episodes of sundowning can be part of a comprehensive assessment, it is not the action the nurse should implement during a functional assessment aimed at determining the client's physical capabilities.

Choice C reason: Assisting with values clarification about end-of-life care options is important but is not the primary focus of a functional assessment in a rehabilitation setting.

Choice D reason: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.

A. White blood cell (WBC) count. B. Red blood cell (RBC) count. C. Serum potassium. D. Blood urea nitrogen (BUN). E. Sputum culture and sensitivity. F. Urinalysis.

Correct Answer is ["A","E"]

Explanation

Choice A reason: Monitoring the WBC count can help determine if the antibiotic is effectively treating an infection, as a decreasing count may indicate recovery.

Choice B reason: The RBC count is not typically affected by respiratory infections and is not a direct indicator of antibiotic effectiveness.

Choice C reason: Serum potassium levels are not directly related to the effectiveness of antibiotics for respiratory infections.

Choice D reason: BUN levels are more indicative of kidney function and are not used to evaluate antibiotic effectiveness for respiratory infections.

Choice E reason: A sputum culture and sensitivity test can identify the causative bacteria and determine if the antibiotic is effective.

Choice F reason: Urinalysis is not directly related to respiratory infections but can be part of a broader assessment of health.

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Naxlex Comprehensive Predictor Exams

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the nurse monitor? Select all that apply.

Correct Answer is ["A","E"]

Explanation

For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Patient Data Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?