A nurse is caring for a client who had an open cholecystectomy 24 hours ago.

The client’s vital signs have been stable over the last 24 hours, with the most recent temperature

98.6° F(37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and pulse 78/min, but are now changing.

Which set of vital signs indicates that the nurse should contact the health care provider?

temperature 97.5° F(36.4° C), BP 98/64 mm Hg, pulse 90/min, RR 18/min.

temperature 99.5° F (37.5° C), BP 126/80 mm Hg, pulse 68/min, RR 16/min.

temperature 100.7° F (38.2° C), BP 118/68 mm Hg, pulse 84/min, RR 20/min.

temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min.

Answer and Explanation

The Correct Answer is D

temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min. This set of vital signs indicates that the client may have an infection or sepsis, which are potential complications of an open cholecystectomy. The client has a fever, tachycardia, tachypnea, and hypotension, which are signs of systemic inflammatory response syndrome (SIRS).

Choice A is wrong because it shows mild hypothermia, hypotension, and tachycardia, which could be due to dehydration or blood loss, but not necessarily infection.

Choice B is wrong because it shows a slight fever, normal blood pressure, and bradycardia, which could be due to pain or medication, but not infection.

Choice C is wrong because it shows a low-grade fever, normal blood pressure and pulse, and mild tachypnea, which could be due to inflammation or dehydration, but not infection.

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Correct Answer is D

Explanation

Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.

Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.

Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.

Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.

A. Assessing pain status. B. Administering a placebo. C. Reviewing a pain diary. D. Offering a back massage.

Correct Answer is D

Explanation

A back massage is a type of cutaneous stimulation that can help reduce pain by activating the gate control theory of pain. Cutaneous stimulation is a non-pharmacological intervention that can be delegated to unlicensed assistive personnel (UAP) or nursing assistive personnel (NAP) under the supervision of a registered nurse.

Choice A is wrong because assessing pain status requires critical thinking and clinical judgment, which are skills that only registered nurses have. Pain assessment is not a task that can be delegated to UAP/NAP.

Choice B is wrong because administering a placebo is a type of pharmacological intervention that involves giving a substance that has no therapeutic effect. Placebos are unethical and ineffective for pain management and should not be used by any health care provider.

Choice C is wrong because reviewing a pain diary involves evaluating the patient’s response to pain interventions and adjusting the plan of care accordingly. This is a complex task that requires nursing knowledge and skills and cannot be delegated to UAP/NAP.

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Naxlex Comprehensive Predictor Exams

When providing nursing care to a client, the nurse provides family-centered nursing care. What is the best rationale for this nursing action?

Correct Answer is D

Explanation

A nurse is attempting to use non-pharmacological treatment for pain control. Which treatment could the nurse delegate to the UAP?

Correct Answer is D

Explanation

The client states “I can’t go on anymore. Life sucks and the world would be better off without me.” What is the RN’s best response?

The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?

A nurse is teaching a client with newly diagnosed hemophilia about home care practices. What statements by the client indicate that teaching has been effective? Select all that apply.

A client with congestive heart failure takes furosemide daily. Which breakfast choice should a nurse suggest for this client?

A client in the clinic states, “I already told you I can’t come back on Friday.” Which response by a nurse would be likely to repair the client-nurse relationship?

What pain description is the client with renal calculi most likely to report during an assessment?

A nurse is admitting a client with an exacerbation of chronic obstructive pulmonary disease. What signs would the nurse expect to observe with this client? Select all that apply.