Patient Data

The nurse is implementing new prescriptions.

Click to indicate if each nursing action is appropriate or not appropriate for the client at the current time. Each row must have one response option selected.

Request a prescription for opioid pain medication

Encourage the client to drink 2 liters of fluids per day

Discuss the client's readiness to quit smoking cigarettes

Increase oxygen by nasal cannula

Administer daily potassium supplement

Ambulate the client in the hallway

Answer and Explanation

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

Request a prescription for opioid pain medication: Not appropriate because the client’s pain is mild (4/10) and cardiac-related; opioids are not first-line for mild chest pain and may depress respiratory drive.
Encourage the client to drink 2 liters of fluids per day: Not appropriate because the client has signs of fluid overload (peripheral edema, pleural effusion, elevated BNP). Fluid restriction is typically recommended in heart failure.
Discuss the client's readiness to quit smoking cigarettes: Appropriate; smoking cessation counseling is safe, relevant, and important for long-term cardiac and pulmonary health.
Increase oxygen by nasal cannula: Appropriate; the client’s oxygen saturation is 83%, which is below the target of >92%, so increasing oxygen is clinically indicated.
Administer daily potassium supplement: Appropriate; the client’s potassium level is low (3.2 mEq/L), and supplementation is needed to prevent cardiac arrhythmias, especially with loop diuretics or underlying heart disease.
Ambulate the client in the hallway: Not appropriate at this time due to hypoxia, tachycardia, and active heart failure exacerbation; ambulation should be deferred until stabilized.

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Correct Answer is D

Explanation

A. Anticipating and monitoring for hypothermia is not a primary concern after a thyroidectomy. While vital signs should be monitored, hypothermia is not a common complication of thyroid surgery, so this intervention is not the most important at this stage.

B. Preparing to administer radioactive iodine treatments is unnecessary immediately post-thyroidectomy. Radioactive iodine is typically used in the treatment of hyperthyroidism or thyroid cancer at later stages, not as an immediate postoperative intervention.

C. Resuming antithyroid drug therapy is not indicated after a thyroidectomy because the surgical removal of thyroid tissue eliminates or significantly reduces thyroid hormone production. Postoperative care focuses on monitoring for complications rather than continuing antithyroid medications.

D. Maintaining a semi-Fowler position is the most important intervention. Elevating the head of the bed helps reduce swelling, promotes airway patency, and decreases tension on the surgical site. Airway compromise is a major postoperative risk due to edema or hematoma formation, and positioning is a critical component of preventing respiratory complications in the immediate 12-hour postoperative period.

Correct Answer is [{"id":"drop-zone-0-0","answer":"B"},{"id":"drop-zone-0-1","answer":"D"}]

Explanation

Rationale for correct answers:

Pain: Chest pain (angina) is the heart’s way of signaling "ischemia" (lack of oxygen). By opening the vessel and compressing the plaque, the oxygen supply-demand balance is restored, which directly reduces or eliminates the ischemic pain.
Dysrhythmias: Heart muscle that is deprived of oxygen becomes "irritable." This electrical instability in the ischemic tissue often leads to dangerous dysrhythmias (abnormal heart rhythms). Restoring blood flow stabilizes the electrical conduction system of the heart.

Rationale for incorrect choices:

Vasospasms: These are sudden constrictions of the muscular walls of the artery. While medications (like nitroglycerin) treat vasospasms, a mechanical stent is primarily designed to address physical obstructions (plaque) rather than the physiological spasm of the vessel wall.
Heart Blocks: These are specific delays or interruptions in the electrical signals between the heart's atria and ventricles. While ischemia can cause heart blocks, they are usually managed with pacemakers or by treating the underlying cause, rather than being the primary focus of a standard PCI for plaque compression.

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Medication	Drug Classification	Treatment Goals
Furosemide	_______________	_______________
Digoxin	_______________	_______________
Captopril	_______________	_______________

Patient Data The nurse is implementing new prescriptions. Click to indicate if each nursing action is appropriate or not appropriate for the client at the current time. Each row must have one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?

Correct Answer is D

Explanation

Correct Answer is [{"id":"drop-zone-0-0","answer":"B"},{"id":"drop-zone-0-1","answer":"D"}]

Explanation

A client on the psychiatric unit is making sexual advances towards a nurse. Which action should this nurse implement first?

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

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?

Patient data For each medication, chose the most likely option for drug classification and treatment goal. Medication Drug Classification Treatment Goals Furosemide _______________ _______________ Digoxin _______________ _______________ Captopril _______________ _______________

Patient Data The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The healthcare provider prescribes a liter of normal saline to be infused at a rate of 1.5 mL/kg/hr. The client weighs 176 pounds. The nurse should set the infusion pump to deliver how many mL/hr? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Patient Data

The nurse is implementing new prescriptions.

Click to indicate if each nursing action is appropriate or not appropriate for the client at the current time. Each row must have one response option selected.