The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Keep the bed in the lowest position and initiate seizure and fall precautions.

Place an indwelling urinary catheter and measure strict intake and output.

Maintain elevated positioning of the dependent joints on affected side.

Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Answer and Explanation

The Correct Answer is D

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

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Correct Answer is A

Explanation

Choice A: Observing the insertion site of the suprapubic catheter is an essential assessment for the home health nurse, as this can help detect any signs of infection, inflammation, or leakage. Therefore, this is the correct choice.

Choice B: Palpating the flank area is not a necessary assessment for the home health nurse, as this is not related to the suprapubic catheter. This is a distractor choice.

Choice C: Measuring abdominal girth is not a relevant assessment for the home health nurse, as this is not affected by the suprapubic catheter. This is another distractor choice.

Choice D: Assessing the perineal area is not an important assessment for the home health nurse, as this is not involved in the suprapubic catheter. This is another distractor choice.

A. Administer a half dose now. B. Give another dose C. Mix the next dose with food. D. Withhold this dose

Correct Answer is D

Explanation

Choice A: Administering a half dose now is not a safe instruction for the nurse to provide, as this can result in overdosing or underdosing the infant, depending on how much of the medicine was absorbed or expelled. This is a contraindicated choice.

Choice B: Giving another dose is not a prudent instruction for the nurse to provide, as this can cause digoxin toxicity, which can be life-threatening for the infant. This is another contraindicated choice.

Choice C: Mixing the next dose with food is not a relevant instruction for the nurse to provide, as this does not address the current situation and can affect the absorption and effectiveness of digoxin. This is a distractor choice.

Choice D: Withholding this dose is a sensible instruction for the nurse to provide, as this can prevent adverse effects and allow the infant's serum digoxin level to be checked before giving another dose. Therefore, this is the correct choice.

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The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is A

Explanation

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is D

Explanation

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The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

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The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

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

After receiving report, the nurse can most safely plan to assess which client last?

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?