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Patient Data

The nurse has provided discharge education to the parent. Click to highlight the findings that would indicate the client's condition is improving.

Client is resting comfortably in the parent's arms. A large amount of dark yellow urine is noted in the diaper. The client is able to tolerate 8 ounces (240 mL) of formula. Rhonchi breath sounds are noted with cough. A small amount of crusted eye drainage is noted. Is afebrile with a normal respiratory and heart rate. Moist, clammy skin is noted.

Client is resting comfortably in the parent's arms.

A large amount of dark yellow urine is noted in the diaper.

The client is able to tolerate 8 ounces (240 mL) of formula.

Rhonchi breath sounds are noted with cough.

A small amount of crusted eye drainage is noted.

Is afebrile with a normal respiratory and heart rate.

Moist, clammy skin is noted.

Answer and Explanation

The Correct Answer is ["A","C","F"]

Rationale:

• Client is resting comfortably in the parent's arms: Improved comfort and the ability to rest calmly indicate reduced distress and better overall physiological stability. In infants with measles, decreased irritability often reflects improvement in fever control and systemic symptoms. Comfort also suggests that pain, headache, and malaise are less severe.

• The client is able to tolerate 8 ounces (240 mL) of formula: Improved oral intake indicates recovery from nausea and fatigue associated with acute viral illness. Adequate feeding supports hydration, caloric needs, and immune recovery in infants. Tolerance of a full feeding without vomiting suggests gastrointestinal symptoms are resolving.

• Is afebrile with a normal respiratory and heart rate: Resolution of fever and normalization of vital signs reflect reduced systemic inflammation and improved physiological status. Fever and tachycardia were prominent earlier findings, so their absence indicates effective symptom control. Normal respiratory rate also suggests reduced metabolic stress.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Intravenous (IV) human albumin: Albumin is used to expand plasma volume and manage complications such as ascites or hepatorenal syndrome. It does not reduce serum ammonia levels or improve hepatic encephalopathy. Confusion related to cirrhosis requires direct management of ammonia accumulation.

B. Furosemide: Furosemide promotes diuresis and is commonly used to manage fluid overload in cirrhosis. It does not address elevated ammonia or neurologic symptoms of hepatic encephalopathy. Diuretic use without correcting ammonia levels would not improve mental status.

C. Lactulose: Lactulose lowers serum ammonia by acidifying the colon and converting ammonia to ammonium, which is then excreted in stool. It also reduces ammonia-producing gut bacteria and promotes fecal elimination. This mechanism directly targets hepatic encephalopathy and improves confusion.

D. Loperamide: Loperamide decreases intestinal motility and stool frequency. In hepatic encephalopathy, suppressing bowel movements increases ammonia absorption. Its use would worsen neurologic symptoms rather than correct the underlying problem.

A. Microwave oven. B. Security wand. C. Toaster. D. Electric blanket.

Correct Answer is B

Explanation

Rationale:
A. Microwave oven: Microwaves do not generate electromagnetic interference strong enough to affect a pacemaker. The client can safely use a microwave without risk to the device’s function.

B. Security wand: Hand-held security wands used in airports or some buildings can emit electromagnetic fields that may interfere with pacemaker function. The client should avoid prolonged or close exposure and notify security personnel about the pacemaker.

C. Toaster: Household appliances such as toasters generate minimal electromagnetic interference and are safe for clients with pacemakers. Normal use does not affect device operation.

D. Electric blanket: Modern electric blankets produce low-level electromagnetic fields that are generally considered safe for pacemaker recipients. Brief, standard use does not interfere with pacemaker function.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

An older adult client is being discharged after implantation of a permanent pacemaker. The client should be instructed to avoid which item?

Correct Answer is B

Explanation

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse determines the client and spouse understand the stroke education when they verbalize that dropdown will dropdown.

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The nurse is monitoring a client with a transcutaneous pacemaker that is periodically failing to capture. Which intervention should the nurse implement first?