The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

Start an IV bolus of lactated Ringer's solution.

Stay with the client for the first 15 min of the transfusion.

Obtain the first unit of packed RBCs from the blood bank.

Document the blood product transfusion in the client's medical record.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Answer and Explanation

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

A. Start an IV bolus of lactated Ringer's solution: Not Indicated

- The client's medical record does not indicate a need for fluid resuscitation or immediate volume replacement.

B. Stay with the client for the first 15 min of the transfusion: Not Indicated

- There is no mention of a blood transfusion in the provided information. Therefore, staying with the client during a transfusion is not relevant.

C. Obtain the first unit of packed RBCs from the blood bank: Not Indicated

- There is no indication of a need for a blood transfusion in the client's assessment findings.

D. Document the blood product transfusion in the client's medical record: Not Indicated
- Since there is no indication of a blood transfusion, documenting a transfusion is not relevant.

E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: Not Indicated
- While it's important to monitor and maintain the client's blood pressure, the provided information does not suggest that the client's blood pressure is significantly low (90/60 mm Hg) or that they are receiving any infusions that need titration for blood pressure management.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A.Jogging or any form of vigorous exercise, especially high-impact activities, should generally be avoided for at least 4–6 weeks after retinal surgery. This is because high-impact activities can increase intraocular pressure and potentially disrupt the healing retina. Jogging involves bouncing or jolting movements, which could adversely affect the repair.

B. Bending at the waist places increased pressure on the eye and can disrupt the healing process after retinal surgery. This action increases intraocular pressure and is typically discouraged postoperatively.

C. Light lifting, such as lifting objects under 10 pounds, is typically allowed after several weeks of recovery, once the initial healing has occurred and the client is no longer at risk for increasing intraocular pressure or straining the surgical site.

D. While sewing itself is a low-impact activity, the act of sewing typically involves bending over or placing the head below the waist, which could still increase intraocular pressure. Early postoperative instructions often caution against activities that involve bending or straining the eyes, such as sewing, reading, or watching TV for extended periods.

D. Correct. After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.

A. Leaving a nasogastric tube clamped after administering oral medication B. Placing a yellow bracelet on a client who is at risk for falls C. Administering potassium via IV bolus D. Documenting communication with a provider in the progress notes of the client's medical record

Correct Answer is C

Explanation

A. Incorrect. Leaving a nasogastric tube clamped after administering oral medication is a mistake, but it may not necessarily be considered malpractice if it doesn't result in harm or negligence.
B. Incorrect. Placing a yellow bracelet on a client at risk for falls is a safety measure, and it's not an example of malpractice.
C. Correct. Administering potassium via IV bolus can be dangerous and is considered malpractice if not done properly. Rapid administration of potassium via IV bolus can lead to serious cardiac complications.
D. Incorrect. Documenting communication with a provider in the progress notes of the client's medical record is a standard practice and not an example of malpractice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

Correct Answer is C

Explanation

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require an dropdown as evidenced by the client's dropdown.

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?

A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take?