A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

Confusion

Blurred vision

Diarrhea

Polyuria

Answer and Explanation

The Correct Answer is A

Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.

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Correct Answer is A

Explanation

Bananas are one of the fruits that contain proteins similar to those found in natural rubber latex, which can cause an allergic reaction in some people. This is called latex-fruit syndrome and can also occur with other fruits such as avocado, kiwi, chestnut, and papaya. The client should inform the surgical team about their banana allergy and avoid contact with latex products such as gloves, catheters, syringes, and bandages.

A. Describe the sensations the client will feel during the procedure. B. Reinforce the importance of lying still during the procedure. C. Administer a sedative medication. D. Determine whether the client has an allergy to local anesthetics.

Correct Answer is D

Explanation

The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.

Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.

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A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

Correct Answer is A

Explanation

A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Correct Answer is D

Explanation

A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)

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A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect?

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?