The nurse is reviewing the female client's medical record.

The nurse is planning care for the client.

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Administer regular insulin.

Place client on 1,500 mL fluid restriction.

Increase supplemental oxygen to keep oxygen saturation greater than or equal to 959%.

Obtain sputum culture.

Answer and Explanation

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

• Administer regular insulin: The client’s glucose increased from 120 mg/dL to 195 mg/dL, which is a common stress response in infection. Short-acting insulin may be anticipated to manage hyperglycemia during acute illness. Controlled glucose levels help reduce infection complications and support healing in clients with type 2 diabetes.

• Place client on 1,500 mL fluid restriction: The client shows signs of dehydration risk, including thirst, fever, and increased BUN at 25 mg/dL. With infection and fluid losses from fever, a restriction would worsen hydration status. The client is already receiving IV fluids to maintain volume and support perfusion, so limiting fluids would be harmful.

• Increase supplemental oxygen to ≥95%: The client’s oxygen saturation is 89% on 2 L/min, which is below target and indicates worsening oxygenation. Increasing oxygen flow is appropriate to improve gas exchange in pneumonia and COPD exacerbation. Maintaining higher saturations prevents respiratory fatigue and tissue hypoxia.

• Obtain sputum culture: The client has fever, productive cough with yellow sputum, and chest X-ray-confirmed pneumonia. A sputum culture helps identify the causative organism and guide antibiotic therapy. Culture results can optimize treatment effectiveness and prevent antibiotic resistance.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I will be able to stop taking this medication when I feel better.": Abruptly stopping sertraline can lead to withdrawal symptoms and potential relapse of depression. Clients need to continue the medication as prescribed and taper under guidance if discontinuation is necessary.

B. "I understand I might experience difficulty concentrating while on this medication.": Difficulty concentrating is a common early side effect of sertraline, an SSRI. Understanding and anticipating this transient effect indicates the client has received appropriate education about expected medication responses.

C. "I should decrease my sodium intake while on this medication.": There is no specific restriction on sodium intake when taking sertraline. This statement reflects a misunderstanding of dietary precautions related to the medication.

D. "I am at an increased risk for developing chronic respiratory problems.": Sertraline does not increase the risk of chronic respiratory issues. This statement shows a misconception about the potential side effects of the medication.

A. Case manager B. Physical therapist C. Occupational therapist D. Nurse manager

Correct Answer is A

Explanation

A. Case manager: A case manager coordinates care for clients with chronic conditions or complex health needs. For a newborn with an atrial septal defect, the case manager can arrange follow-up appointments, provide education to the family about monitoring for symptoms, and ensure access to cardiology services. This referral supports continuity of care and helps prevent complications.

B. Physical therapist: Physical therapy focuses on improving mobility, strength, and motor function. While important for certain conditions, a newborn with an atrial septal defect typically does not require routine physical therapy unless there are additional developmental or musculoskeletal concerns. It is not the primary referral for cardiac follow-up.

C. Occupational therapist: Occupational therapy helps clients develop fine motor skills and perform daily activities. For a newborn with a heart defect, OT is usually not indicated unless developmental delays or feeding difficulties are present. Cardiac management and follow-up are more urgent concerns at discharge.

D. Nurse manager: The nurse manager oversees nursing staff and unit operations rather than providing direct patient follow-up or discharge planning. Referral to the nurse manager does not address the newborn’s ongoing care needs after discharge and is not part of standard interprofessional follow-up for an atrial septal defect.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for sertraline to treat depression. Which of the following statements by the c indicates an understanding of the medication treatment plan?

Correct Answer is B

Explanation

A nurse is preparing to discharge a newborn who has an atrial septal defect. The nurse should expect the provider to refer the client to which of the following interprofessional team members?

Correct Answer is A

Explanation

A nurse is caring for a preschool-age child who has a short-leg plaster cast applied 1 hr ago. Which of the following is an appropriate intervention

A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure?

A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate?

A nurse is assessing a client who has COPD and experienced recent weight loss. Which of the following findings should the nurse report provider immediately?

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?

A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?

A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects?