Scenario

A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the client's condition evolves and whether it worsens or improves.

1500 hrs - Follow-Up Assessment

Exhibits

Based on the 1500 hrs assessment, categorize the following actions for the client.

Increasing IV fluid rate

Encouraging the client to sit up without assistance

Administering antiemetic medication

Monitoring respiratory rate closely

Providing reassurance and calming interventions

Checking electrolyte levels regularly

Answer and Explanation

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

Action	Essential	Nonessential	Contraindicated
Increasing IV fluid rate		The current rate is prescribed by the provider; increasing it without further assessment could lead to complications.
Encouraging the client to sit up without assistance		The client feels faint upon sitting up and is unsteady, so this could be dangerous.
Administering antiemetic medication	Helpful but not immediately critical.
Monitoring respiratory rate closely	Crucial due to client's rapid breathing and anxiety.
Providing reassurance and calming interventions	Important due to client's anxiety and discomfort.
Checking electrolyte levels regularly	Essential for ongoing monitoring given the client's symptoms.

Essential

Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.
Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.
Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.
Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B,D,E,C,A

Explanation

The correct order of Erikson’s stages of psychosocial development from birth to adolescence is:

Trust vs. mistrust
Autonomy vs. shame and doubt
Initiative vs. guilt
Industry vs. inferiority
Identity vs. role confusion

A. “I should pad the mattress in my baby’s crib so that he will be more comfortable when he sleeps.”. B. “I will place my baby on his stomach when he is sleeping.”. C. “I should remove extra blankets from my baby’s crib.”. D. “I should place my baby’s crib next to the heater to keep him warm during the winter.”. .

Correct Answer is C

Explanation

Choice A rationale

Padding the mattress in a baby’s crib can pose a suffocation risk and is not recommended for crib safety22.

Choice B rationale

Placing a baby on their stomach for sleep, known as prone sleeping, increases the risk of sudden infant death syndrome (SIDS). Babies should always be placed on their back to sleep22.

Choice C rationale

Removing extra blankets from a baby’s crib is a key part of crib safety. Loose bedding can pose a suffocation risk22.

Choice D rationale

Placing a baby’s crib next to a heater could lead to overheating, which is a risk factor for SIDS. It’s important to keep the baby’s sleep environment at a comfortable temperature22.

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Essential

Nonessential

Contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson’s stages of psychosocial development in order from birth to adolescence.

Correct Answer is B,D,E,C,A

Explanation

A nurse is educating a new parent about crib safety.Which statement by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a toddler.The nurse’s observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next?

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