A nurse in the emergency room is assessing a patient who was brought in following a seizure. The nurse suspects the patient may have bacterial meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves.

Decrease environmental stimuli.

Close the room.

Administer an antipyretic.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing the cranial nerves is important, but it is not the immediate next step after implementing droplet precautions for suspected bacterial meningitis.

Choice B reason: Decreasing environmental stimuli can help reduce the risk of seizures and is a supportive measure for a patient with suspected bacterial meningitis.

Choice C reason: Closing the room is part of implementing droplet precautions but is not an action that needs to be initiated by the nurse as it should already be in place.

Choice D reason: Administering an antipyretic may be necessary if the patient has a fever, but it is not the immediate next action after droplet precautions.

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Correct Answer is C

Explanation

Choice A reason: Acute pain is expected with a fracture but does not specifically indicate impaired venous return.

Choice B reason: Ecchymosis, or bruising, can occur with a fracture due to bleeding into the tissue but is not a direct indicator of venous return issues.

Choice C reason: Increasing edema is a sign of impaired venous return as it indicates a buildup of fluid in the tissues, which can occur if the veins are not effectively returning blood to the heart.

Choice D reason: A diminishing distal pulse could indicate arterial impairment rather than venous return issues.

A. Headache B. Dyspnea C. Red-brown petechiae D. Altered mental status

Correct Answer is B

Explanation

Choice A reason: Headache can be associated with FES; however, it is not typically considered an early sign. It may occur as a part of the broader spectrum of symptoms.

Choice B reason: Dyspnea, or difficulty breathing, is one of the earliest signs of FES. Patients may experience shortness of breath due to fat globules obstructing pulmonary vessels.

Choice C reason: Red-brown petechiae, which are small, pinpoint hemorrhages, can appear on the skin and are a classic sign of FES, often found in the axillary region or on the chest.

Choice D reason: Altered mental status, including confusion and drowsiness, can occur early in FES due to fat emboli traveling to the cerebral circulation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client’s affected arm?

Correct Answer is C

Explanation

A nurse is assessing a client who is 24 hours postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)?

Correct Answer is B

Explanation

A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?

A nurse in a Post Anesthesia Care Unit (PACU) is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during the assessment? (Select all that apply.)