A client has a diagnosis of risk for suicide r/t a past attempt. Which of the following outcome should the nurse prioritize?

The client will verbalize 3 positive attributes about themselves by day 3

The client will perform personal hygiene with no prompting

The client will attend group by day 2

The client will remain free from injury for duration of their hospitalization

Answer and Explanation

The Correct Answer is D

A. The client will verbalize 3 positive attributes about themselves by day 3. This is a good long-term goal but does not directly prevent self-harm.

B. The client will perform personal hygiene with no prompting. Improved self-care is beneficial but is not the primary priority in suicide prevention.

C. The client will attend group by day 2. Participation in therapy is helpful, but ensuring physical safety takes precedence.

D. The client will remain free from injury for the duration of their hospitalization. The most critical goal for a client at risk for suicide is preventing self-harm, making this the priority outcome.

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Correct Answer is A

Explanation

A. Discharge teaching: Phase III of post-anesthesia care focuses on preparing the patient for discharge, including teaching about post-operative care, medication instructions, and follow-up care.

B. Recovery from anesthesia: This occurs in Phase I, where patients are closely monitored as they emerge from anesthesia and regain protective reflexes.

C. Urinary catheterization if no voiding: This may be considered in Phase II, especially if urinary retention is present, but is not a defining activity of Phase III.

D. Vital signs every 15 to 30 minutes: Frequent monitoring of vital signs is a key part of Phase I, when patients are at the highest risk for complications.

A. Numbness of fingers B. Dry skin C. Abdominal pain D. Lethargy

Correct Answer is D

Explanation

A. Numbness of fingers. Numbness or tingling (paresthesia) is more common in respiratory alkalosis due to low CO₂ levels causing calcium binding changes.

B. Dry skin. Respiratory acidosis does not typically cause dry skin; rather, it may cause cyanosis or flushed skin due to CO₂ retention.

C. Abdominal pain. Abdominal pain is more commonly seen in metabolic acidosis, not respiratory acidosis.

D. Lethargy. Respiratory acidosis leads to CO₂ retention, which depresses the central nervous system, causing lethargy, confusion, and even coma in severe cases.

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A client has a diagnosis of risk for suicide r/t a past attempt. Which of the following outcome should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action is completed during phase III of post anesthesia care?

Correct Answer is A

Explanation

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

The nurse provides care to a patient admitted with a respiratory disorder. Which laboratory finding is most concerning?

A nurse is caring for a client who has metabolic acidosis. Which of the following could be a cause for the for metabolic acidosis?

Which identifier should the nurse use during the initial time-out to determine the right patient?

Which of the following is an example of a nursing diagnosis?

The nurse performs in-line suctioning when the patient experiences a decrease in oxygen saturation and bradycardia. Which nursing action is best?

Which of the following is a characteristic of tardive dyskinesia?

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?