Patient Data

Exhibits

Data is evaluated to determine possible condition and appropriate interventions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for Correct Answers:

Delirium: The client shows sudden confusion, difficulty remembering events, disorientation to time and place, and inconsistent attention span. These symptoms developed acutely after surgery, indicating delirium rather than dementia or depression, which have slower onset and different characteristics.
Institute fall precautions: Delirium increases fall risk due to confusion, impaired judgment, and unawareness of physical limitations. This client has already shown poor safety awareness (e.g., forgetting what a call light is), making fall precautions essential.
Reorient to environment: Repeated verbal reminders of place, time, and situation help reduce confusion and anxiety in delirious patients. The client is unsure why she is hospitalized and forgets instructions, making reorientation a key nursing strategy.
Nutritional intake/intake and output: The client is eating poorly and has signs of dehydration (dry mucosa, tenting). Monitoring intake and output supports correction of fluid/electrolyte imbalances, which can worsen delirium if untreated.
Drug therapy: Older adults are more sensitive to medication side effects, especially those that affect cognition. Monitoring the effects of prescribed drugs is crucial since inappropriate or excessive medication can contribute to or worsen delirium.

Rationale for Incorrect Answers:

Dementia: Dementia presents as a chronic, progressive decline in cognitive function. The client’s confusion is recent, fluctuates, and appeared postoperatively, which is not consistent with the gradual, irreversible decline typical of dementia.
Depression: While older adults may have decreased appetite or low energy due to depression, the client’s acute confusion, memory loss, and inability to perform familiar tasks point more strongly toward delirium rather than mood-related impairment.
Remove all objects that could cause harm: While this may be helpful in some situations, the client is not displaying aggressive behavior or intentional self-harm. Delirium management focuses more on supervision, reorientation, and safety support.
Family involvement: While helpful in long-term care, family involvement is not the most immediate or measurable parameter in evaluating acute delirium. The priority is physiologic stabilization and cognitive assessment.
Intracranial pressure: There is no evidence of increased ICP (e.g., no severe headache, vomiting, pupil changes). Delirium is more likely due to metabolic or environmental factors, not intracranial pressure elevation in this context.

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Correct Answer is []

Explanation

Rationale for Correct Answers:

Febrile nonhemolytic transfusion reaction: This is the most likely condition, as the child became flushed and complained of a headache shortly after transfusion began. These are hallmark signs of this common reaction caused by recipient antibodies reacting to donor leukocytes or cytokines.
Stop the blood transfusion: This is the priority action for any suspected transfusion reaction. It immediately halts exposure to the triggering product and allows further assessment and appropriate treatment.
Apply supplemental oxygen: Oxygen supports tissue perfusion and prevents hypoxia, especially important in a client with symptomatic anemia and a potential transfusion reaction. It is a key supportive intervention.
Respiratory rate: RR is a vital early indicator of hypoxia or respiratory distress. Monitoring it during and after a transfusion helps detect complications like hypoxemia or worsening perfusion.
Oxygen saturation: SpO₂ helps assess how well the client is oxygenating. It is essential during transfusions, particularly in symptomatic children with low hemoglobin and potential oxygen delivery deficits.

Rationale for Incorrect Options:

Transfusion-associated graft versus host disease: This reaction typically occurs days to weeks after transfusion and presents with fever, rash, diarrhea, and liver dysfunction. It is rare and not consistent with immediate symptoms like flushing and headache.
Administer an antipyretic: While this may be used later to manage fever, it should not be the first action. Administering it before stopping the transfusion risks masking the reaction and delaying the most critical intervention.
Send blood for type: Blood typing is a pre-transfusion procedure. The client has already received typed and crossmatched blood, so re-typing does not help address the current transfusion reaction symptoms.
Blood pressure: While BP monitoring is part of routine care, it is not the most sensitive indicator in this reaction. The client's BP is already low and should be tracked, but it does not guide early detection of respiratory distress.
Platelet count: Platelet count is not useful for identifying or monitoring febrile transfusion reactions. It assesses bleeding risk but does not reflect the client’s response to transfused red blood cells.

A. Cup of raspberries. B. Bowl of oatmeal. C. Scrambled eggs. D. Raisin bran muffins. E. Bacon slices.

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

Explanation

A. Cup of raspberries: Raspberries are high in dietary fiber and water content, making them an excellent choice to promote soft stools and reduce straining during bowel movements.

B. Bowl of oatmeal: Oatmeal is rich in soluble fiber, which helps bulk up and soften stools, aiding in the prevention of hemorrhoid irritation and constipation.

C. Scrambled eggs: Eggs are low in fiber and do not contribute to stool softening or bowel regulation, so they are not beneficial for a high-fiber diet.

D. Raisin bran muffins: These are typically made with whole grains and dried fruit, both good sources of dietary fiber that help improve bowel regularity.

E. Bacon slices: Bacon contains no fiber and is high in fat and sodium, which may worsen constipation and hemorrhoid symptoms.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.)

Correct Answer is []

Explanation

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

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

Explanation

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?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.