The nurse is continuing to care for the client.

Exhibits

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed? For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Heart rate

Blood pressure

Edema

Deep tendon reflexes

Answer and Explanation

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

Finding	Improved	Not changed
Heart rate		✓
Blood pressure	✓
Edema	✓
Deep tendon reflexes	✓

Rationale

Heart rate: Not changed
- The heart rate increased from 72/min to 90/min, indicating no improvement.
Blood pressure: Improved
- The blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg, indicating improvement.
Edema: Improved
- The edema decreased from +3 pitting to +2 pitting, indicating improvement.
Deep tendon reflexes: Improved
- The patellar reflex decreased from 4+ to 2+, indicating improvement.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. High-pitched stridor suggests airway obstruction, not heart failure.

B. Reduced right-sided breath sounds can indicate pleural effusion or pulmonary congestion, common in clients with heart failure.

C. Intercostal retractions indicate respiratory distress, usually associated with conditions like asthma or pneumonia.

D. Paradoxical chest movement is a sign of flail chest, not heart failure.

A. Wear a face shield prior to entering the client's room. B. Place a mask on the client prior to transport. C. Use an alcohol-based hand rub following client care. D. Remove the protective gown while in the client's room.

Correct Answer is D

Explanation

A. A face shield is unnecessary unless there is a risk of splashing.

B. Masks are not needed for C. difficile, as it is not spread through airborne transmission.

C. Alcohol-based hand rubs are ineffective against C. difficile spores; handwashing with soap and water is required.

D. Contact precautions for C. difficile require the nurse to remove the protective gown and gloves inside the client's room to prevent contamination of outside areas.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?

A nurse is caring for a client in an acute care setting. Exhibits Complete the following sentence by using the list of options. The client is at risk for _________ as evidenced by _______.

A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?

A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed ______ and will need to be monitored for _________.

A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?

A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client on an acute mental health unit. Exhibits Complete the following sentence by using the list of options. The nurse should delegate the client's ____________ and focus on _________