Patient Data

Exhibits

After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic.

Drag from Word Choices to complete the sentence.

The nurse determines that the findings are reflective of
and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Uremic Encephalopathy: The client has chronic kidney disease and elevated blood urea nitrogen (BUN) levels, indicating impaired kidney function. Symptoms such as feeling tired, fever, and possibly altered mental status can be associated with uremic encephalopathy, a condition that arises from the accumulation of toxins in the blood due to kidney failure.

Fluid Volume Overload: The client has elevated blood pressure (140/86 mm Hg), an irregular and elevated heart rate (117 beats/minute), and respiratory rate (36 breaths/minute), which can be signs of fluid volume overload. Additionally, the slight bibasilar infiltrates observed in the chest X-ray suggest potential fluid accumulation in the lungs.

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Correct Answer is ["B","H"]

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9°C) B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg. D. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.

Correct Answer is A

Explanation

A. The client with viral meningitis and a slight increase in temperature can be managed by a PN, as this change in status is less acute and requires standard nursing care and monitoring.

B. The client with myxedema coma experiencing a significant drop in blood pressure requires more complex and immediate intervention by an RN due to the critical nature of the condition.
C. The client with a subdural hematoma and a significant change in blood pressure needs close monitoring and potential interventions by an RN, given the risk of increased intracranial pressure.
D. The client with diabetic ketoacidosis and a decreased Glasgow Coma Scale score is in a critical state requiring close monitoring and management by an RN.

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Patient Data Exhibits After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic. Drag from Word Choices to complete the sentence. The nurse determines that the findings are reflective of and

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What 2 orders should the nurse complete first?

Correct Answer is ["B","H"]

Explanation

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Correct Answer is A

Explanation

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Patient Data

Exhibits

After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic.

Drag from Word Choices to complete the sentence.

The nurse determines that the findings are reflective of
and