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Patient Data

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.
Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Notify the social worker the client is awake.

Explain all procedures

Increase the propofol infusion

Consider extubating the client

Have the client sign consent forms for procedures already performed

Assess the client's pain

Determine the client's decision-making ability

Decrease the noise and light stimuli in the room as much as possible

Answer and Explanation

Correct Answer : B,F,G,H

A. Notify the social worker the client is awake: The social worker is already attempting to contact family. Awakening does not require immediate notification; the priority is client care and stabilization.

B. Explain all procedures: As the client becomes more alert, clear explanations reduce anxiety, promote cooperation, and support orientation, especially in the ICU environment.

C. Increase the propofol infusion: Increasing sedation without clinical indication may mask neurological changes and hinder assessment. Sedative adjustments should be based on prescribed parameters and provider orders.

D. Consider extubating the client: Extubation is only considered when specific respiratory and hemodynamic criteria are met. Waking up does not automatically mean the client is ready to be extubated.

E. Have the client sign consent forms for procedures already performed: Consent must be obtained prior to procedures. Once completed, retroactive consent is not valid or ethical.

F. Assess the client’s pain: Pain assessment is essential in postoperative and trauma patients, particularly once the client is able to communicate.

G. Determine the client’s decision-making ability: As the client becomes more awake, assessing cognitive status and ability to participate in care decisions is appropriate and supports autonomy.

H. Decrease the noise and light stimuli in the room as much as possible: Minimizing environmental stimuli helps reduce delirium risk, improves comfort, and promotes healing in critically ill patients.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Encourage positive self accolades for dietary adherence: While supportive reinforcement is helpful for long-term behavior change, it does not address the immediate problem of vomiting and inability to tolerate food and liquids.

B. Determine if the client is over-hydrating to feel satiated: Assessing hydration habits may be part of long-term dietary counseling, but it is not the priority intervention when the client is acutely vomiting and unable to tolerate intake.

C. Maintain the client on an NPO status: Keeping the client NPO prevents further vomiting, reduces the risk of aspiration, and allows the gastrointestinal tract to rest. This is the immediate priority intervention in managing post-bariatric surgery complications such as obstruction or delayed gastric emptying.

D. Administer daily vitamin supplements: Vitamins are important for nutritional maintenance after bariatric surgery, but administering them orally is not appropriate when the client cannot tolerate food or liquids. Nutritional support should be deferred until tolerance improves.

A. Green leafy vegetables. B. Avocados and cheese. C. Yogurt or buttermilk. D. Fresh fruits.

Correct Answer is C

Explanation

A. Green leafy vegetables: While nutritious and high in vitamins and minerals, green leafy vegetables do not specifically counteract the gastrointestinal effects of antibiotics like cefdinir. They are not directly relevant to maintaining gut flora during antibiotic therapy.

B. Avocados and cheese: These foods provide healthy fats and protein but do not restore beneficial gut bacteria disrupted by antibiotics. They are nutritious but not the primary dietary focus for this purpose.

C. Yogurt or buttermilk: Probiotic-rich foods like yogurt or buttermilk help maintain normal gastrointestinal flora, reducing the risk of antibiotic-associated diarrhea and promoting gut health during cefdinir therapy. Including these foods supports the client’s digestive system while on antibiotics.

D. Fresh fruits: Fruits are rich in vitamins and fiber but do not specifically replace beneficial bacteria lost during antibiotic therapy. They are supportive nutritionally but do not directly prevent gastrointestinal side effects.

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Patient Data Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Correct Answer is C

Explanation

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Patient Data Exhibits Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

Patient Data Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address dropdown. In addition, he will need interventions to prevent dropdown_.

Patient Data

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.
Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.