A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Potential Prescription: Anticipated /Nonessential /Contraindicated

Encourage the client to cough.

Keep the client's head in a midline position.

Elevate the head of the bed.

Assist the client to the bathroom.

Initiate seizure precautions.

Decrease oxygen to 1.5 L/min via nasal cannula.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

A)   Coughing is not directly related to the client's condition as described in the scenario.
B)   Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C)   Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D)   Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E)   Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F)   Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A) Offering reassurance about the outcome of the procedure may not address the client's specific fears.
B) Encouraging the client to discuss their concerns allows the nurse to address any misconceptions or fears the client may have and provide appropriate information and support.
C) Assuming the client's fear is related to needles may not be accurate and may not address their specific concerns.
D) Asking the client to explain why they are scared is a good approach, but it may not immediately address their fears or provide the support they need.

A. Distended jugular veins B. Pitting, dependent edema C. Decreased blood pressure D. Increased blood pressure

Correct Answer is C

Explanation

A) Distended jugular veins are associated with fluid overload, not dehydration.

B) Pitting, dependent edema is also associated with fluid overload, not dehydration.

C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse. "I am afraid to have this procedure." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

Correct Answer is C

Explanation

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