A client reports pain worsening in their right forearm, rating the pain as 7 on a scale of 0 to 10. The client also states their right hand is "tingly.”. The client is able to move their fingers.

The client is avoiding eye contact with staff and is more withdrawn.

The client's adult child is at the bedside.

The client appears drowsy and less alert, but is oriented to person, place, time, and situation.

The client's apical pulse is regular, and their lungs are clear to auscultation.

A report is given to the operating room nurse, and the client is en route to the surgical suite via gurney for repair of a right radial fracture.

Encourage the client to ambulate to the bathroom.

Check the client's peripheral pulses and capillary refill.

Elevate the client's arm above the level of the heart.

Administer a sedative to help the client relax.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Encouraging the client to ambulate to the bathroom would be inappropriate and potentially harmful. The client is experiencing worsening pain, tingling, and is on a gurney en route to surgery for a fractured radius. Ambulation could exacerbate the injury, increase pain, and risk further complications. Mobility should be restricted until the fracture is stabilized and the client is post-operative.

Choice B rationale

This is the correct action as it assesses for potential complications of compartment syndrome, a critical and urgent condition. The worsening pain and tingling are classic symptoms. Compartment syndrome occurs when pressure builds within the fascial compartments, compromising circulation. A loss of peripheral pulses and delayed capillary refill are late signs of impaired circulation and are key indicators for this limb-threatening emergency.

Choice C rationale

Elevating the arm above the heart would decrease arterial blood flow to the injured extremity, which could worsen tissue perfusion and potentially lead to ischemia. For a client with a suspected circulatory compromise, such as with compartment syndrome, the arm should be kept at the level of the heart to maintain adequate blood flow.

Choice D rationale

Administering a sedative could mask the client's symptoms, particularly the level of pain and changes in mental status, which are crucial indicators of their deteriorating condition. The client's pain is a vital sign that needs to be continuously monitored, and sedation would hinder the nurse's ability to accurately assess for changes in their neurovascular status. .

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Correct Answer is A

Explanation

Choice A rationale

Spironolactone is a potassium-sparing diuretic. Its mechanism of action involves blocking aldosterone receptors in the kidney's distal convoluted tubule and collecting duct, leading to increased sodium and water excretion while retaining potassium. Consequently, taking a potassium supplement concurrently would dangerously increase the risk of hyperkalemia, a condition characterized by high blood potassium levels (normal range is 3.5-5.0 mEq/L), which can cause life-threatening cardiac dysrhythmias.

Choice B rationale

Spironolactone's primary effect is on sodium and potassium balance, not calcium. Calcium supplements do not typically interact with spironolactone in a way that would cause a significant, adverse change in calcium levels. The nurse should instruct the client to avoid supplements that directly alter the electrolytes affected by the medication's mechanism of action.

Choice C rationale

Spironolactone does not significantly impact iron metabolism. Therefore, a client taking an iron supplement would not be at increased risk of an adverse interaction. Iron supplements are generally well-tolerated with spironolactone, and there is no contraindication for their concurrent use. The focus of client teaching should be on electrolytes directly affected by the medication.

Choice D rationale

Spironolactone does not have a direct or clinically significant interaction with magnesium supplements. While diuretics can sometimes affect magnesium levels, spironolactone's primary action is on potassium and sodium. Therefore, there is no major contraindication for the use of magnesium supplements, unlike the life-threatening risk associated with potassium supplementation. *.

A. During this test, I must not eat or drink anything. B. This test will tell me if my baby has a genetic problem. C. During this test, I will push a button if my baby moves. D. I will get oxytocin during this test.

Correct Answer is C

Explanation

Choice A rationale

A nonstress test (NST) does not require the client to fast. The client can eat and drink normally, and sometimes a sugary beverage is even encouraged to stimulate fetal movement, as the test aims to record fetal heart rate accelerations in response to these movements.

Choice B rationale

The nonstress test is a screening tool used to assess fetal well-being by measuring the fetal heart rate's response to fetal movement. It does not provide information about genetic problems, which are typically identified through genetic testing or prenatal diagnostic procedures such as amniocentesis.

Choice C rationale

A key component of the nonstress test involves the mother noting fetal movements. The client is given a marker, often a button, to press each time she feels the baby move. This action correlates the mother's perception of movement with the fetal heart rate accelerations recorded on the monitor.

Choice D rationale

Oxytocin is not administered during a nonstress test. The purpose of this test is to assess the baby's baseline heart rate and accelerations without external stimulation. Oxytocin is used in a contraction stress test, which is a different procedure to evaluate how the baby handles uterine contractions. *.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over-the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?

Correct Answer is A

Explanation

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

The nurse is preparing to speak to the facility’s social worker about the client’s condition. Select the 5 findings the nurse should plan to include in the report.

A nurse is teaching a client who has a new prescription for levothyroxine about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?

A nurse is assessing a client who states that she becomes extremely anxious in social gatherings. She tells the nurse that she never feels "good enough" for her coworkers. The nurse should identify that these findings can indicate which of the following personality disorders.