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Find patient data below.

Exhibits here

What actions should the nurse plan for the rest of the shift? Select all that apply.

Monitor the oxygen saturation

Discuss aggressive respiratory treatment options

Obtain a sputum culture

Allow the client to take a position of comfort

Discuss with the client potential asthma triggers

Consider positive pressure ventilation

Wean the supplemental oxygen

Prepare for deep tracheal suctioning

Answer and Explanation

Correct Answer : A,D,E

A)   Correct- Continuous monitoring of oxygen saturation ensures the client's oxygen levels remain within an acceptable range.
B)   Incorrect - Discussing aggressive respiratory treatment options is not warranted based on the provided information. The current treatment plan includes appropriate interventions.
C)   Incorrect - Obtaining a sputum culture is important for identifying infections, but it's not an immediate action in the context of the client's current symptoms.
D)   Correct- Promoting comfort can help reduce anxiety and potentially improve breathing.
E)   Correct- Educating the client about potential triggers supports better self-management.
F)   Incorrect - Considering positive pressure ventilation is not indicated at this stage. The client's symptoms are being managed with other interventions.
G)   Incorrect - Weaning supplemental oxygen is not mentioned in the patient data or nurses' notes as something that's currently necessary.
H)   Incorrect - Preparing for deep tracheal suctioning is not warranted based on the patient data and the current treatment plan.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.

A. Use a cushion when sitting. B. Perform range of motion exercises. C. Document abdominal girth. D. Weigh every morning.

Correct Answer is D

Explanation

This is the best intervention for the PN to implement because it monitors the client's ﬂuid status and helps detect ﬂuid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.

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Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

Correct Answer is B

Explanation

A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

Correct Answer is D

Explanation

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

When gathering data about a client with dark skin tones, which site should the practical nurse (PN) observe?

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?

Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Find patient data below.

Exhibits here

What actions should the nurse plan for the rest of the shift? Select all that apply.