The nurse is continuing to assist in the care of the client post-surgery. The test-taker must interpret the following exhibits to answer the question.

The nurse is assisting with evaluating the client’s responses to interventions.

Exhibits
Based on the exhibits and findings, which findings indicate that the client’s condition is improving? Select all that apply

Oxygen saturation

Hemoglobin

Mental status

Urinary output

WBC count

Answer and Explanation

Correct Answer : C,E

Choice A rationale:

Oxygen saturation is not provided in the exhibits, so there is no data available to evaluate if it indicates improvement in the client’s condition. While oxygen saturation is an important indicator of respiratory function and overall oxygenation status, its absence means it cannot be used to assess the client’s progress in this case.

Choice B rationale:

Hemoglobin levels decreased from 14 g/dL on postoperative day 1 to 10.5 g/dL on postoperative day 2. This decline in hemoglobin levels suggests that the client may be experiencing blood loss or anemia, which is not indicative of improvement. Generally, an improvement in the client’s condition would be reflected in stable or increasing hemoglobin levels rather than a decrease.

Choice C rationale:

Mental status is an important indicator of overall recovery and improvement. On postoperative day 2, the client is described as drowsy but alert to voice. This level of responsiveness indicates an improvement in mental status compared to what might be expected immediately post-surgery. A client who is drowsy but still responsive to verbal stimuli is showing signs of regaining consciousness and cognitive function, which is a positive sign of recovery.

Choice D rationale:

Urinary output is not provided in the exhibits, so there is no data available to assess if it indicates improvement. Urinary output is an important measure of kidney function and fluid status, but without specific data, it cannot be used to determine the client’s progress.

Choice E rationale:

The WBC count increased from 7,000/mm³ on day 1 to 8,500/mm³ on day 2, which is within the normal range and indicates a healthy immune response.

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Correct Answer is B

Explanation

Choice A rationale

Encouraging fluids with meals is not the best choice for a client who has HIV. While hydration is important, drinking fluids with meals can fill the stomach and decrease the client’s appetite, potentially leading to inadequate nutrient intake.

Choice B rationale

Offering small, frequent meals is a recommended intervention for a client who has HIV. This approach can help to maximize nutrient intake and manage symptoms such as nausea and early satiety. This is the correct choice.

Choice C rationale

While fresh fruits and vegetables are generally part of a healthy diet, they may not be appropriate for all clients with HIV. Some individuals may have difficulty digesting these foods, and others may be at risk of infection from uncooked produce.

Choice D rationale

Providing a diet of pureed foods is not a standard intervention for clients with HIV. This approach may be necessary for individuals with certain conditions or symptoms, but it is not applicable to all clients with HIV23.

A. Initiate seizure precautions. B. Assist the patient to the bathroom. C. Keep the patient’s head in a mid position. D. Decrease oxygen to 1.5 L/min via nasal cannula.

Correct Answer is A

Explanation

Choice A rationale

Without specific patient data, it’s challenging to provide a detailed rationale.

However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.

Choice B rationale

Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.

Choice C rationale

Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.

Choice D rationale

Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?

Correct Answer is B

Explanation

A nurse is reviewing a patient’s medical record.After reviewing the medical data, which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

Exhibits The nurse is reviewing the client’s findings. The client is at the highest risk for developing dropdown due to dropdown/p>

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