The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's
dropdown
followed by the client's
dropdown

Answer and Explanation

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

Rationale:

Elevated blood glucose: A random glucose level of 220 mg/dL is mildly elevated and can be expected during acute illness or stress, especially in clients with diabetes. It should be monitored but does not require immediate intervention in this cardiac context.
Elevated heart rate: A heart rate of 116/min reflects tachycardia, which may result from pain, anxiety, or reduced cardiac output. While it is an important finding, it is secondary to more urgent issues like chest pain or myocardial injury.
Epigastric discomfort: Epigastric discomfort alone is not an emergency finding and can occur in non-cardiac conditions such as GERD or peptic ulcer disease. While it may signal atypical angina, it lacks the specificity or urgency of active chest pain.
Chest pain: Chest pain is a classic symptom of myocardial ischemia and warrants immediate intervention. The nurse should apply oxygen, initiate cardiac monitoring, assess pain characteristics, establish IV access, and prepare to administer nitroglycerin or aspirin per protocol.
Elevated troponin: A troponin level of 10.15 ng/mL confirms myocardial injury and supports the diagnosis of myocardial infarction. The nurse should report this result immediately, anticipate further cardiac workup, continue ECG and vital monitoring, and prepare the client for possible transfer to a higher level of care.
Elevated blood pressure: A BP of 158/92 mm Hg is elevated but not critical in this context. It is likely a response to pain or anxiety and can be managed after more urgent issues, such as ischemia or infarction, have been addressed.

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Correct Answer is B

Explanation

Rationale:
A. "Lie down after meals.": Lying down after eating increases the risk of gastric contents refluxing into the esophagus due to gravity. Clients with GERD should remain upright for at least 2 to 3 hours after meals to minimize symptoms.
B. "Elevate the head of the bed while sleeping.": Elevating the head of the bed by 6 to 8 inches helps prevent nighttime reflux by using gravity to reduce backward flow of stomach acid into the esophagus, which is a key strategy in GERD management.
C. "Eat a snack 1 hour before going to bed.": Eating close to bedtime can exacerbate GERD symptoms by increasing gastric volume and acid production, especially when the client lies down soon after eating. A longer gap between the last meal and sleep is advised.
D. "Eat three large meals each day.": Large meals increase gastric pressure and acid production, worsening reflux symptoms. Clients with GERD should eat smaller, more frequent meals to reduce gastric distension and minimize acid reflux episodes.

A. Chest tube output B. Respiratory rate C. Trachea position D. Urine output E. O₂ saturation F. Blood pressure G. Heart rate H. Temperature

Correct Answer is ["A","C","E","F"]

Explanation

Rationale:

Chest tube output: A sudden stop in chest tube drainage following bright red output earlier can indicate tube obstruction or clot formation. This is concerning post-lobectomy, as blocked drainage may lead to tension pneumothorax or fluid accumulation.
Respiratory rate: A rate of 18/min is within normal limits and shows no signs of distress or compromise. Therefore, it does not require immediate reporting.
Trachea position: A shift from midline to deviated trachea suggests mediastinal shift, potentially due to a developing tension pneumothorax. This is a medical emergency and must be reported immediately.
Urine output: A urine output of 110 mL over one hour is well within normal limits and indicates adequate kidney perfusion. The expected minimum is 30 mL/hr, so this value does not raise concern for hypoperfusion or renal impairment. There is no need to report this finding to the provider at this time.
O₂ saturation: A drop from 92% to 89% on room air is clinically significant, especially after thoracic surgery. Hypoxia in this context may signal impaired lung function or emerging complications like pneumothorax.
Blood pressure: The client’s blood pressure dropped from 130/80 mm Hg to 110/60 mm Hg within one hour. While 110/60 mm Hg is still within normal range, the sudden 20 mm Hg drop in systolic pressure may indicate early hemodynamic instability, especially postoperatively.
Heart rate: A heart rate of 70/min is normal and stable, showing no signs of bradycardia or tachycardia that would warrant concern at this stage.
Temperature: A decrease in temperature from 37.2°C to 36.4°C is not clinically alarming postoperatively and does not suggest infection or hypothermia. No need for immediate reporting.

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The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdown followed by the client's dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client on a medical surgical unit. Exhibits Which client findings should the nurse report to the provider immediately? (Select all that apply.)

Correct Answer is ["A","C","E","F"]

Explanation

A nurse is assessing the lumbar puncture results of an older adult client who has bacterial meningitis. Which of the following laboratory findings should the nurse expect?

A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client's plan of care?

A nurse is caring for a client who is mechanically ventilated and is agitated. The nurse notices the client attempts to reach the endotracheal tube. Which of the following actions should the nurse take?

A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)?

The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdown followed by the client's dropdown

A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?

A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?

The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's
dropdown
followed by the client's
dropdown