A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first
dropdown
and then
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Administer sublingual nitroglycerin. Nitroglycerin is a first-line treatment for angina or suspected myocardial infarction. It dilates coronary arteries, improving blood flow and reducing myocardial oxygen demand.
Apply supplemental oxygen. Routine oxygen administration is no longer recommended unless the client is hypoxic (oxygen saturation below 90%) because excessive oxygen can lead to vasoconstriction and worsen myocardial injury.
Obtain a 12-lead ECG. While an ECG is important for diagnosing myocardial infarction, the priority in an acute chest pain episode is symptom relief and hemodynamic stability. The ECG should already have been obtained at admission.
Administer morphine sulfate IV. Morphine is used to manage severe chest pain that is not relieved by nitroglycerin. It reduces myocardial oxygen demand, preload, and anxiety, which can help relieve symptoms.
Monitor vital signs. Continuous monitoring is essential, but it is not the most immediate intervention in an acute episode of worsening chest pain. The focus should be on relieving ischemia and reducing myocardial workload.
Educate the client about smoking cessation. While smoking cessation is critical for long-term cardiovascular health, education is not a priority when the client is experiencing acute chest pain requiring immediate intervention.

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Correct Answer is D

Explanation

A. Difficulty swallowing. While difficulty swallowing (dysphagia) can be associated with certain conditions, it is not a typical indicator of unrelieved pain in a client receiving a spinal epidural. This symptom may be related to neurological involvement or medication side effects and should be assessed further.
B. Constipation. Opioids used in conjunction with epidural anesthesia can contribute to constipation, but this is a side effect rather than a direct indicator of pain. Constipation can also result from reduced mobility or decreased fluid intake, so it should be managed appropriately but does not necessarily reflect uncontrolled pain.
C. Urinary retention. Epidural anesthesia can affect bladder function by impairing the sensation of fullness and the ability to void. While urinary retention is a common side effect of epidural use, it is not a direct sign of unrelieved pain. Monitoring for bladder distention and assessing for the need for catheterization is important.
D. Clenched teeth. Clenching the teeth is a physical manifestation of pain, often indicating discomfort and distress. Clients experiencing unrelieved pain may also exhibit other nonverbal cues such as grimacing, restlessness, or guarding. The nurse should assess pain using an appropriate scale and notify the provider if pain is not adequately controlled.

A. Encourage the client to use the overbed trapeze. B. Keep a loose, absorbent dressing over the client's surgical site. C. Maintain abduction of the client's residual limb with a pillow. D. Caution the client to avoid a prone position while in bed.

Correct Answer is A

Explanation

A. Encourage the client to use the overbed trapeze. Using an overbed trapeze helps the client build upper body strength, which is essential for mobility and independence following an amputation. Strengthening the arms and shoulders facilitates bed mobility, transfers, and eventual prosthetic use.
B. Keep a loose, absorbent dressing over the client's surgical site. The surgical site should be covered with a secure, sterile dressing to promote healing and prevent infection. Loose dressings can shift, increasing the risk of contamination and delayed wound healing.
C. Maintain abduction of the client's residual limb with a pillow. Prolonged abduction is not recommended, as it can lead to hip contractures. The limb should be kept in a neutral or slightly extended position to maintain proper alignment and prevent muscle shortening that could interfere with prosthetic use.
D. Caution the client to avoid a prone position while in bed. Prone positioning is actually encouraged intermittently to help stretch the hip flexors and prevent contractures. Avoiding this position may increase the risk of hip flexion contractures, making prosthetic fitting and ambulation more difficult.

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A nurse is assisting with the care of a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should first dropdownand thendropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

Correct Answer is D

Explanation

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

Correct Answer is A

Explanation

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

A nurse is reinforcing discharge teaching with a client who has heart failure. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Exhibits Which of the following findings requires further action by the nurse? Select all that apply.

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first
dropdown
and then
dropdown