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Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Have the client sign consent forms for procedures already performed

Assess the client's pain

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

Explain all procedures

Consider extubating the client

Notify the social worker the client is awake.

Increase the propofol infusion

Determine the client's decision-making ability

Answer and Explanation

Correct Answer : B,C,D,H

A. Have the client sign consent forms for procedures already performed: Consent must be obtained before a procedure unless it’s an emergency. Signing after the fact is not valid and serves no legal or clinical purpose.

B. Assess the client's pain: As the client becomes more alert, pain assessment is essential. She may now be able to report discomfort, and timely pain management is critical for trauma recovery and comfort.

C. Decrease the noise and light stimuli in the room as much as possible: Reducing environmental stimuli can help prevent agitation, confusion, and sensory overload as the client becomes more aware. This is especially important in the ICU setting.

D. Explain all procedures: Providing explanations promotes trust and reduces anxiety. As the client regains awareness, clear communication supports orientation and psychological comfort during care.

E. Consider extubating the client: Extubation decisions are made based on respiratory stability, not solely on alertness. The client’s respiratory parameters and readiness criteria must be met before considering extubation.

F. Notify the social worker the client is awake: While eventual involvement is important, awakening does not require immediate social work notification unless related to emotional distress or decision-making.

G. Increase the propofol infusion: Increasing sedation is not appropriate unless the client is agitated or in distress. As the client wakes appropriately, sedation should be weaned, not increased.

H. Determine the client's decision-making ability: As the client becomes more alert, evaluating her ability to understand and make decisions is appropriate. This helps guide future consent and care planning.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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

Explanation

Support Ventilation:

PaCO₂ 42 mm Hg: This value falls within the normal range of 35–45 mm Hg, indicating adequate ventilation and effective CO₂ removal. It supports that the client's ventilator settings are maintaining proper respiratory function.
pH 7.40: A normal arterial blood pH indicates stable acid-base status, suggesting that respiratory and metabolic functions are balanced. This reflects effective ventilatory support and tissue perfusion.

Prevent Infection:

Surgical dressing dry and intact: A dry, intact dressing helps maintain a sterile barrier over the surgical site, reducing the risk of contamination. It indicates no active bleeding or signs of surgical wound infection.
Temperature 98.1°F: A normothermic reading helps support immune function and prevent infection. In trauma care, avoiding hypothermia is also important in preventing coagulopathy and sepsis.

Manage Hypovolemia:

Blood pressure 112/77 mm Hg: This blood pressure is within a normal range, showing stable perfusion and likely adequate volume status after earlier hypotension. It indicates a positive response to fluid management.
Capillary refill 2 seconds: A refill time under 2–3 seconds indicates good peripheral perfusion and supports adequate intravascular volume. It is a quick, non-invasive indicator of circulatory status.

Control Pain and Anxiety:

Pain 0 on a scale of 0 to 10: A pain score of 0 indicates successful pain control, which helps prevent agitation, reduces metabolic demand, and supports healing. Adequate pain management also minimizes stress response.

A. The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. B. The incision dressing is dry and intact, and no bleeding is noted. C. The client tolerated clear liquids post recovery and has advanced to a soft diet. D. The client ambulated around the unit this morning and tolerated activity well. E. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO. F. The client is currently resting in bed.

Correct Answer is ["B","C","D","E"]

Explanation

• Incision dressing is dry and intact, with no bleeding: Indicates proper wound healing and absence of complications such as infection or hemorrhage. A clean, dry surgical site is a key criterion for safe discharge.

• Tolerated clear liquids and advanced to soft diet: Shows that the gastrointestinal system is functioning post-anesthesia and surgery. Tolerance of oral intake without nausea, vomiting, or abdominal discomfort is essential before discharge.

• Ambulated around the unit and tolerated activity well: Demonstrates that the client has regained baseline mobility, which reduces risk of postoperative complications like atelectasis or DVT. Ability to mobilize is a standard requirement for safe discharge.

• Bowel sounds present in all four quadrants; passing flatus: Confirms the return of peristalsis and bowel function, which is necessary before discharge after abdominal surgery. Passing gas is an expected milestone indicating GI recovery.

• Pain controlled with oral analgesia: Suggests that the client’s pain is manageable without IV medication. Effective pain control at home using oral medications supports comfort and reduces the risk of readmission.

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Patient Data 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

Client data Complete the table by matching each client data to the appropriate goal of care

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

Explanation

Correct Answer is ["B","C","D","E"]

Explanation

Exhibits Select the 4 assessment findings that require immediate follow up.

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

Patient Data

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.