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A nurse in a provider's office is caring for a client.

Click to highlight the findings from the current visit that indicate an improvement in the client's condition. To deselect a finding, click on the finding again.

Nurses' Notes

Current visit:

Client here for follow-up visit. Was seen 1 week ago for worsening manifestations of heart failure. +1 nonpitting edema noted to feet and ankles. Client reports shortness of air improved and only occurs with significant exertion. Also states has more energy and is sleeping better. Client does report episodes of nausea and decreased appetite. Also states has had occasional dizziness. Today's weight is 78.9 kg (174 lb).

Was seen 1 week ago for worsening manifestations of heart failure

+1 nonpitting edema noted to feet and ankles

Client reports shortness of air improved and only occurs with significant exertion

Also states has more energy

and is sleeping better

Client does report episodes of nausea and decreased appetite

Also states has had occasional dizziness

Today's weight is 78.9 kg (174 lb)

Answer and Explanation

The Correct Answer is ["B","C","D","E","H"]

+1 nonpitting edema noted to feet and ankles: The reduction from +3 pitting edema to +1 nonpitting edema indicates improved fluid status and decreased venous congestion, reflecting effective management of heart failure symptoms.
Client reports shortness of air improved and only occurs with significant exertion: Dyspnea with minimal activity has improved to only occurring with significant exertion, suggesting enhanced cardiac output and better pulmonary perfusion.
Client states has more energy: Increased energy demonstrates improved tissue perfusion and oxygen delivery, indicating stabilization of heart failure symptoms.
Client states is sleeping better: Better sleep reflects decreased nocturnal dyspnea and improved overall cardiac function.
Weight decreased from 82.1 kg (181 lb) to 78.9 kg (174 lb): Weight loss in a client with heart failure indicates effective diuresis, reduced fluid retention, and improved volume status.

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

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Correct Answer is A

Explanation

A. Respirations deep at a rate of 10/min: Morphine depresses the respiratory center in the brainstem, leading to hypoventilation. A respiratory rate of 10/min indicates early respiratory depression, which is the most life-threatening adverse effect and requires immediate intervention.

B. Vomiting 30 mL of fluid: Nausea and vomiting are common side effects of morphine but are not immediately life-threatening. They can be managed once airway and breathing are stable.

C. Blood pressure 90/60 mm Hg: Mild hypotension is a possible side effect of morphine due to vasodilation but is less critical than respiratory compromise. Monitoring and fluid support may be required, but it is not the priority.

D. Urinary output of 20 mL within 1 hr: Morphine may cause urinary retention, but this finding is not immediately life-threatening. It should be addressed after ensuring adequate ventilation and oxygenation.

A. Medication reconciliation report B. Root cause analysis form C. Plan of care D. Occurrence report

Correct Answer is D

Explanation

A. Medication reconciliation report: A medication reconciliation report is used to compare the client’s current medications with new prescriptions to prevent errors during transitions of care. It is not used to document incidents or near misses.

B. Root cause analysis form: A root cause analysis is a detailed process performed after a serious adverse event to determine underlying system issues. It is not the initial documentation tool for a single medication error or near-miss.

C. Plan of care: The plan of care outlines nursing interventions and goals for the client’s treatment. It is not used to record or report medication-related incidents.

D. Occurrence report: An occurrence (incident) report is the appropriate document for recording medication errors or near misses, such as discovering an allergy before administration. It provides information for quality improvement and risk management without becoming part of the client’s medical record.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should identify that which of the following is the priority finding?

Correct Answer is A

Explanation

A nurse is preparing to administer a dose of ampicillin to a client. The nurse scans the medication and the client's identification band and realizes the client has a penicillin allergy. Which of the following should the nurse use to document the incident?

Correct Answer is D

Explanation

A nurse is caring for a client who received verapamil 1 hr ago and now has a blood pressure of 80/54 mm Hg. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who requires a re-insertion of a short peripheral venous catheter. In which of the following locations should the nurse place the catheter?

A nurse is teaching a client who has diabetes mellitus and a new prescription for a combination of lispro insulin and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a client who is taking furosemide to treat heart failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

A nurse is caring for a client who received succinylcholine IV bolus during an abdominal surgery. The client develops malignant hyperthermia. The nurse should administer which of the following medications?

A nurse is assessing a client who has heart failure and is receiving furosemide BID via IV bolus. Which of the following findings should the nurse identify as an adverse effect of the medication?

A nurse is caring for a client who has a new prescription for methimazole for hyperthyroidism. Which of the following findings should the nurse report to the provider as a potentially life-threatening adverse effect?

A nurse is teaching a newly licensed nurse about medication reconciliation. The nurse should instruct the newly licensed nurse to perform medication reconciliation for which of the following clients?