Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by

Decreased muscle tone, relaxed jaw muscles, sagging mouth

Congestion/increased pulmonary secretions; noisy respirations (death rattle)

Altered breathing (apnea, labored or irregular breathing, Cheyne- Stokes pattern)

Urine output is clear yellow

Eating soft foods

Answer and Explanation

Correct Answer : A,B,C

As patient goes into cardiorespiratory failure, there is altered breathing with characteristic gasping and death rattle before complete cessation of breathing. This is followed by cessation of the peripheral nervous system with loss of tone.

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Correct Answer is C

Explanation

"I'm sorry, but your child's medical Information is none of your business."This response is confrontational and dismissive, and it doesn't effectively address the parents' concerns. It's important to maintain professionalism and respect even in challenging situations.

"I can only give medical Information to your child because they are legally an adult."This response respects the minor's emancipated status and acknowledges that, legally, the nurse can only disclose medical information to the emancipated minor themselves. It upholds the principles of patient confidentiality and autonomy while also providing clear and accurate information to the parents about their limitations regarding access to their child's medical information.

"The healthcare provider will share this information with you," could potentially mislead the parents because it implies that the healthcare provider will provide them with the information directly. However, if the minor is legally emancipated, the healthcare provider would still be bound by confidentiality laws and would only be able to disclose information to the minor themselves unless there are extenuating circumstances or legal exceptions.

I can give you those results as soon as I get them back from the laboratory."While this response offers to provide information, it doesn't address the issue of confidentiality or the parents' role in receiving the information. It's also not accurate to promise the results directly without involving the healthcare provider, who is responsible for interpreting and discussing the results with the patient and family.

A. Basilar lung sounds that are diminished in the left lung. B. Contraction of the left pupil when light shines in the right eye. C. Active bowel sounds in the lower right quadrant. D. Capillary refill of 2 seconds in the lower right foot.

Correct Answer is A

Explanation

A. Reduced lung sounds could indicate consolidation in a pneumonic process
B. Contraction of the left pupil upon shining light into the right is a normal response referred to as the consensual pupillary response
C. Active bowel sounds are a normal finding and not considered an exception.
D. A capillary refill time within the normal range (usually less than 2 seconds) is a normal finding and not considered an exception.

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Patient Data Exhibits Drag from the Word Choices to complete the sentence. The nurse determines the client is near death as evidenced by

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Naxlex Comprehensive Predictor Exams

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is A

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by