The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Implement an intervention.

Perform an assessment

Develop a nursing diagnosis.

Evaluate an outcome.

Answer and Explanation

The Correct Answer is D

A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.

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Correct Answer is C

Explanation

A) Menorrhagia: This term refers to heavy or prolonged menstrual bleeding. It does not relate to the absence of menstrual flow.
B) Dysmenorrhea: This term describes painful menstruation or menstrual cramps. It is not used to indicate the absence of menstrual flow.
C) Amenorrhea: This term is used to describe the absence of menstrual flow. It can be primary (never having had a menstrual period) or secondary (the cessation of menstruation after having had periods previously).
D) Metrorrhagia: This term refers to bleeding that occurs between menstrual periods. It does not describe the absence of menstrual flow.

A. Wear socks when walking around the home. B. Install grab bars in the bathtub. C. Secure rugs with adhesive tape. D. Use nightlights along stairways and walkways. E. Install handrails on both sides of all stairways.

Correct Answer is ["B","C","D","E"]

Explanation

A) Wear socks when walking around the home: Wearing socks, especially if they have smooth soles, can increase the risk of slipping on hard surfaces. Non-slip footwear is recommended for preventing falls. Therefore, recommending socks for walking may not address the safety concerns effectively.
B) Install grab bars in the bathtub: Installing grab bars in the bathtub is a crucial safety measure for preventing falls and providing support for older adults while bathing. This helps reduce the risk of slips and injuries in a common high-risk area for falls.
C) Secure rugs with adhesive tape: Securing rugs with adhesive tape helps prevent them from slipping, which can significantly reduce the risk of tripping and falling. Loose or unsecured rugs are common hazards in the home environment.
D) Use nightlights along stairways and walkways: Using nightlights along stairways and walkways improves visibility and helps prevent falls during the night. Adequate lighting is essential for older adults to navigate their homes safely.
E) Install handrails on both sides of all stairways: Installing handrails on both sides of stairways provides additional support and stability, which is particularly important for older adults to prevent falls while using stairs. This enhancement helps ensure safer navigation of stairs.

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The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting assessment data on a new client. The client states she does not have a menses. What term will the nurse use in her documentation to describe the absence of menstrual flow?

Correct Answer is C

Explanation

Which of the following should the nurse include in her teaching plan to address home safety for an older adult client? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A patient is diagnosed with Receptive Aphasia. The nurse understands this patient can:

When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about?

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?

A Community nurse is doing a class teaching measures to prevent peripheral arterial disease. Select all that apply teaching for this topic. (Select All that Apply.)

During a respiratory physical assessment, the nurse directs the patient to say and repeat the letter E for the transmitted voice sounds assessment. The nurse by auscultation hears the letter A instead of E. This is known as:

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best?