The client is a 49-year-old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history

The client has an oxygen saturation of 96% on 8 L simple face mask. The nurse assesses the client, and he is feeling less restless and anxious. His heart rate is now 79 bpm, blood pressure 119/73 mmHg, and respiratory rate 24.

What are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge?

The client will report pain less than 3/10

The client will have quit smoking

The client will remain free of skin breakdown

The client will maintain oxygen saturation of 96% without supplemental oxygen

The client will be afebrile for 24 hours

Answer and Explanation

Correct Answer : B,D,E

A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. After straight catheterization, assessing for residual urine volume in the bladder helps determine if the bladder has emptied adequately. Palpation of the client's bladder can provide information about residual urine volume.

B. Replacing the catheter with an indwelling catheter is not indicated unless there are specific reasons for continuous drainage.

C. Allowing the bladder to empty further without assessing for residual distention may lead to incomplete bladder emptying, which can cause urinary retention and discomfort.

D. Clamping the catheter for thirty minutes is not appropriate after straight catheterization and may result in urinary retention or discomfort for the client.

A. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty B. Perform daily surgical dressing change for a client who had an abdominal hysterectomy C. Initiate patient controlled analgesia (PCA pumps for two clients immediately postoperatively. D. Start the second blood transfusion for a client twelve hours following a below knee amputation E. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)

Correct Answer is ["A","B","E"]

Explanation

A. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. Rationale: This task is within the scope of practice for a practical nurse, who can monitor and report changes in a patient's vital signs postoperatively.

B. Perform daily surgical dressing change for a client who had an abdominal hysterectomy.
Rationale: A practical nurse is trained to perform dressing changes, which is a routine postoperative care task.
C. Initiate patient controlled analgesia (PCA pumps for two clients immediately
postoperatively. Rationale: This task is typically reserved for registered nurses as it requires assessment and specialized knowledge in pain management.
D. Start the second blood transfusion for a client twelve hours following a below knee amputation. Rationale: Initiating blood transfusions is generally the responsibility of a registered nurse due to the complexity and potential complications involved.
E. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). Rationale: A practical nurse can administer medications, including insulin, as per the sliding scale protocol under the supervision of a registered nurse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse serves that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Correct Answer is C

Explanation

The nurse is caring for a group of clients with the help of a practical nurse (PN) Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 6 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dl (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?