How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse in a medical-surgical unit is caring for a clent

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the

followed by the client .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Choices:

  • Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
  • Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

  • Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
  • Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
  • Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
  • Blood glucose level:  Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

Rationale:

A. Massage the client's legs once every 8 hr while the stockings are in place: Massaging the legs of a client at risk for thromboembolism is discouraged, as it could dislodge a clot and lead to a pulmonary embolism. Mechanical methods like stockings are preferred for promoting circulation.

B. Fold the top of the stocking over neatly: Folding the stockings creates a tourniquet effect, restricting venous return and potentially increasing the risk of venous stasis or skin breakdown. Stockings should remain flat and unfolded.

C. Determine if the stockings are binding: It’s important to assess for tightness, especially at the toes and calves, to ensure proper circulation and prevent pressure injuries. Stockings should fit snugly but not impair blood flow.

D. Apply the stockings after the client is in a chair: Stockings are most effective when applied while the client is in a supine position, before blood pools in the lower extremities. Delayed application reduces their preventive benefit.

Correct Answer is D,A,B,C

Explanation

Rationale:

A. Insert the catheter until resistance is felt: The catheter should be gently advanced into the tracheostomy tube until resistance is met, which typically indicates reaching the carina.

B. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch): Slight withdrawal prevents trauma to the carina and positions the catheter optimally for effective suctioning.

C. Rotate the catheter while suctioning: Rotating the catheter as suction is applied allows for even clearing of secretions along the tracheal walls and helps prevent localized tissue damage.

D. Lubricate the catheter with sterile saline: Lubrication ensures smooth insertion and reduces trauma to the tracheal mucosa. This is the first action after applying sterile gloves.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register