The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Select 1 condition and 1 client finding to fill in each blank in the following sentence.

After collecting data from the client, the nurse should identify that the client is experiencing

as evidenced by the client's

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Placenta previa: Placenta previa occurs later in pregnancy and is characterized by painless bright red vaginal bleeding without abdominal tenderness. The client is only 6 weeks pregnant, and placenta previa is not a concern this early in gestation.
abruptio placentae: Abruptio placentae involves painful bleeding and a rigid uterus, usually occurring after 20 weeks' gestation. The client’s gestational age and presenting symptoms are more consistent with an early pregnancy complication rather than abruptio placentae.
ectopic pregnancy: This occurs when a fertilized egg implants outside the uterus. The client’s missed period, positive pregnancy test, right lower quadrant tenderness, and dark red vaginal spotting are classic signs of ectopic pregnancy. Ectopic pregnancy is a life-threatening emergency if rupture occurs, requiring prompt identification and management.
acute asthma attack: While the client has a history of asthma and slight inspiratory wheezing, her respiratory status is stable with normal oxygen saturation and no signs of acute respiratory distress. Therefore, an asthma attack is not the primary concern.
pyelonephritis: Pyelonephritis typically presents with fever, chills, flank pain, and urinary symptoms. The client’s presentation of right lower quadrant tenderness and vaginal spotting does not align with the typical findings of pyelonephritis.
respiratory rate: The client’s respiratory rate is normal at 16/min, indicating stable respiratory function. Respiratory rate does not explain the primary concern related to abdominal pain and vaginal bleeding.
history of regular menstrual period: While this supports that the client is late in her cycle, it is not the most direct or critical finding pointing toward the diagnosis. The focus should be on current clinical signs like abdominal tenderness.
temperature: The client’s temperature is within normal range at 37.3°C (99.1°F), making infection less likely and not the primary concern related to her current symptoms.
right lower quadrant abdominal tenderness: Localized tenderness in the right lower quadrant combined with vaginal spotting strongly suggests an ectopic pregnancy. This is a hallmark finding that supports the diagnosis as the growing embryo can cause irritation, stretching, or rupture of the fallopian tube.
hyperactive bowel sounds: Hyperactive bowel sounds are nonspecific and can occur due to anxiety, mild gastrointestinal upset, or pain, but they are not diagnostic for ectopic pregnancy. The abdominal tenderness is the more significant finding.

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Correct Answer is C

Explanation

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.

A. Allergy to penicillins B. Allergy to macrolides C. Allergy to sulfonamides D. Allergy to tetracyclines

Correct Answer is B

Explanation

A. Allergy to penicillins: Penicillin allergies are important when prescribing beta-lactam antibiotics like amoxicillin, but azithromycin is not a penicillin; it belongs to the macrolide class, so this allergy is not directly relevant.

B. Allergy to macrolides: Azithromycin is a macrolide antibiotic. An allergy to macrolides must be reported immediately because administering azithromycin could trigger an allergic reaction, which could be serious or life-threatening.

C. Allergy to sulfonamides: Sulfonamide allergies are relevant when prescribing medications like sulfamethoxazole-trimethoprim, but azithromycin does not belong to the sulfonamide class.

D. Allergy to tetracyclines: Tetracyclines are a different class of antibiotics, used for infections such as acne or certain respiratory infections. An allergy to tetracyclines is not a concern when administering azithromycin.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

Correct Answer is C

Explanation

A nurse in a health clinic is assisting in the care of a client diagnosed with chlamydia. The client was prescribed azithromycin 1 g PO once. Which of following allergy findings in the client's history should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

A nurse at a provider's office is caring for a client. Select the 3 findings that require immediate follow-up.

A nurse is caring for a client who has acute appendicitis and speaks a different language than the nurse. The client is scheduled to undergo an appendectomy. Which of the following actions should the nurse take? (Select all that apply.)

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for ________ due to ________.

A nurse is preparing the body of a client who is deceased to be viewed by the family. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has cirrhosis of the liver. Which of the following findings should the nurse identify as the priority?

A nurse is assisting with the plan of care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional conference?