Patient Data

Exhibits

Each row and each column must have at least one, but may have more than one, response option selected.
Intervention: Promotes safety/ Does not promote safety

Place all client belongings out of reach

Instruct the client to call before getting up

Initiate use of the bed alarm

Complete a swallow study before giving anything by mouth

Place the client in a room near the elevator

Provide a call button kept within reach

Answer and Explanation

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

A.   placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B.   Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C.   Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D.   Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E.   Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F.   Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use Incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

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

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.

F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

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Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

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

Explanation

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

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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?

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

Patient Data

Exhibits

Each row and each column must have at least one, but may have more than one, response option selected.
Intervention: Promotes safety/ Does not promote safety