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A nurse is caring for a client.

Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6° C (99.7° F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Select the 4 findings that require immediate follow-up.

Temperature

Blood pressure

Respiratory rate

Pulse oximetry.

Heart rate.

Level of consciousness

Skin color and temperature

Answer and Explanation

Correct Answer : B,D,E

The blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg.

The pulse oximetry has decreased from 97% to 93%, indicating a decrease in oxygen saturation.

The heart rate has increased from 66/min to 104/min.

The level of consciousness is always an important factor to monitor in a patient.

A. Temperature: The temperature has only changed slightly and is within the normal range.

C. Respiratory rate: The respiratory rate has increased but is still within normal range.

G. Skin color and temperature: This information is not provided in the exhibit.

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Correct Answer is B

Explanation

A nurse should consult an occupational therapist when caring for a client who had a stroke and requires assistance with morning ADLs.
Occupational therapists specialize in helping individuals regain their ability to perform activities of daily living (ADLs) and can provide valuable assistance in this situation.

Choice A is wrong because a physical therapist focuses on improving mobility and physical function.
Choice C is wrong because a speech-language pathologist focuses on improving communication and swallowing abilities.
Choice D is wrong because a registered dietician focuses on nutrition and dietary needs.

A. Place the shallow end of the fracture pan under the client's buttocks. B. Hyperextend the client's back while the fracture pan is in place. C. Encourage the client to try to defecate for 20 min while on the fracture pan. D. Keep the bed flat while the client is on the fracture pan.

Correct Answer is A

Explanation

This statement indicates that the nurse should properly position the fracture bedpan to facilitate its use.
The shallow end of the fracture bedpan should be placed under the client’s buttocks to provide support and comfort.

Choice B is wrong because hyperextending the client’s back can cause discomfort and may not facilitate the use of the fracture bedpan.
Choice C is wrong because it is not necessary for the client to try to defecate for 20 minutes while on the fracture bedpan.
Choice D is wrong because keeping the bed flat may not provide the most comfortable position for the client while using the fracture bedpan.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult?

Correct Answer is B

Explanation

A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

When caring for a client who is receiving a warm, moist compress to relieve lower back pain, which of the following findings should indicate to the nurse that the compress has been effective?

A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage.

A nurse is preparing to administer medication to a client. Which of the following should the nurse use as a client identifier?

A nurse is teaching a client who is about to undergo a bowel resection about advance directives.

A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220 Ib. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.).