A nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Vital Signs

0800:

Blood pressure 112/64 mm Hg

Heart rate 80/min

Respiratory rate 18/min

Temperature 37.1° C (98.8" F

Oxygen saturation 97% on room air

08151

Blood pressure 106/54 mm Hg Heart rate 100/min

Respiratory rate 22/min Temperature 37° C (98,6°F)

Oxygen saturation 95% on room air

Complete the following sentence by using the lists of options.
The client has manifestations of
an , as evidenced by the

Answer and Explanation

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

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A: Correct. Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly.
B: Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel.
C: Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.

A. The reduced muscle tone relaxed the low muscles B. "That happens when a person gets close to death C. "I can apply a chin strap to help hold the mouth closed

Correct Answer is A

Explanation

A. The reduced muscle tone had relaxed the law muscles CORRECT
Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.

B. "That happens when a person gets close to death INCORRECT
This automatic response is nontherapeutic and does not address the family member's question

C. "I can apply a chin strap to help hold the mouth closed INCORRECT
Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

Correct Answer is A

Explanation

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)

Nurse is caring for a client following abdominal surgery. Exhibits Select the findings the nurse should report to the provider.

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

A nurse in an emergency department is caring for a client. Exhibits Complete the following sentence by using the lists of options. The nurse should first review the medications that may be causing the client's dropdown followed by dropdown

A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?