Patient Data

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

Palpate and compare radial pulses.

Provide morphine 2 mg IV push.

Administer ondansetron 4 mg IV push.

Check capillary refill on bilateral upper extremities.

Perform range of motion.

Inspect the bandage for drainage

Answer and Explanation

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

Indicated:

Palpate and compare radial pulses: Comparing radial pulses helps assess vascular integrity in both upper extremities, especially important with trauma and swelling. It can identify compromised circulation, which may occur with displaced fractures or vascular compression.
Provide morphine 2 mg IV push: The client reports severe, constant pain (10/10) in the left arm. Morphine is prescribed and appropriate for controlling acute, post-traumatic pain and preventing complications related to stress and poor pain control.
Administer ondansetron 4 mg IV push: The client reports nausea and fear of vomiting postoperatively. Ondansetron is an antiemetic used to prevent aspiration and reduce discomfort in post-op clients, especially those with limited mobility or recent anesthesia.
Check capillary refill on bilateral upper extremities: Capillary refill is part of neurovascular assessment, which is essential in clients with fractures. It helps detect early signs of impaired perfusion or compartment syndrome, particularly when swelling or displacement is present.
Inspect the bandage for drainage: Postoperative monitoring of the surgical site is critical to detect signs of bleeding, infection, or excessive drainage. Early inspection helps ensure prompt intervention if complications arise.

Contraindicated:

Perform range of motion: Performing ROM on a limb with a displaced humeral fracture is unsafe. Movement can worsen the fracture, increase pain, or disrupt surgical repairs, especially in the acute post-injury or post-op phase.

Nursing Test Bank

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Correct Answer is ["A","C","D"]

Explanation

A. Hydrochlorothiazide: Thiazide diuretics reduce calcium excretion by the kidneys, which can increase serum calcium levels and worsen hypercalcemia in clients with hyperparathyroidism.

B. Acetaminophen: Acetaminophen is not known to affect calcium or parathyroid function, so it is generally safe for pain or fever management in these clients.

C. Lithium carbonate: Lithium can increase parathyroid hormone secretion, thereby exacerbating hyperparathyroidism and hypercalcemia, making it a medication of concern.

D. Calcium carbonate: Calcium supplements can further raise serum calcium levels in clients with hyperparathyroidism, increasing the risk of renal stones or cardiac complications, and should be reviewed.

E. Sodium phosphate supplement: Phosphate supplements can actually lower calcium levels and may be used therapeutically in some cases of hyperparathyroidism, so they are not typically contraindicated.

A. Complete ongoing focused assessments of a client with wrist restraints. B. Supervise a newly hired graduate nurse during an admission assessment. C. Administer PRN oral analgesics to a client with a history of chronic pain. D. Transport a client who is receiving IV fluids to the radiology department.

Correct Answer is B

Explanation

A. Complete ongoing focused assessments of a client with wrist restraints: While initial assessments must be done by an RN, ongoing focused assessments of restraints can often be delegated to a PN under RN supervision according to facility policies.

B. Supervise a newly hired graduate nurse during an admission assessment: Supervising and evaluating a new nurse’s clinical skills, especially during critical tasks like an admission assessment, requires the judgment and responsibility of a fully licensed RN.

C. Administer PRN oral analgesics to a client with a history of chronic pain: Administering PRN oral medications for stable, chronic conditions is a task that a PN can perform, depending on state regulations and facility protocols.

D. Transport a client who is receiving IV fluids to the radiology department: Transporting stable clients with IV fluids can be delegated to a UAP if the IV is well-established and there are no expected complications.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Correct Answer is B

Explanation

A client presents to the emergency department (ED) reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Patient Data

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