Patient Data

Exhibits
The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record.
Nursing Action: Indicated/ Contraindicated

IV 0.9% normal saline continuous infusion at 100

Daily weights

Calculation of intake and output

IV potassium sparing diuretic

Continuous pulse oximetry monitoring

Electrocardiogram monitoring

Answer and Explanation

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

A.   Given the client's chronic kidney disease and the risk of fluid overload, a high rate of normal saline infusion may not be appropriate without careful assessment and specific indication from the healthcare provider.
B.   Monitoring daily weight is essential in managing fluid balance and assessing for potential fluid overload, especially in a child with chronic kidney disease.

C.   Accurate measurement of intake and output is crucial in managing fluid balance and monitoring kidney function, particularly in a patient with a history of acute kidney injury and chronic kidney disease.
D.   The client already has an elevated potassium level, and administering a potassium-sparing diuretic could worsen hyperkalemia, leading to dangerous cardiac complications.
E.   Continuous monitoring of oxygen saturation is important due to the presence of bibasilar infiltrates on the chest X-ray, which could indicate a potential respiratory issue.
F.   ECG monitoring is indicated due to the elevated potassium level (5.3 mEq/L), which can cause cardiac arrhythmias. The irregular heart rate further supports the need for ECG monitoring.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.

C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.

A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis

Correct Answer is A

Explanation

A. Scoliosis is a lateral curvature of the spine. It is commonly assessed during routine physical examinations, especially in adolescents.
B. Lordosis refers to an exaggerated inward curvature of the spine, typically in the lumbar region.
C. Torticollis is a condition characterized by a tilt of the head to one side due to the shortening of muscles on one side of the neck.
D. Kyphosis is an exaggerated outward curvature of the thoracic spine, leading to a rounded upper back.

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Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

Exhibits Nursing actions: Indicated/contraindicated/non-urgent

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

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?

Patient Data

Exhibits
The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record.
Nursing Action: Indicated/ Contraindicated