A nurse is caring for a client who has a spinal cord injury.

Nurses' Notes 0600:

Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.

1000:

Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.

Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions

Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain

For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

Administer nifedipine

Assess blood pressure every 15 min.

Perform suctioning.

Assess for urinary retention.

Place client in supine position.

Withhold pain medication for headache until other manifestations resolve.

Answer and Explanation

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

Anticipated actions for the client include:
- A. Administer nifedipine.

- B. Assess blood pressure every 15 minutes.

-   D. Assess for urinary retention.
Contraindicated actions for the client include:

-   C. Perform suctioning (since there is no indication or information suggesting the need for suctioning).
-   E. Place client in supine position (as it might worsen the symptoms).

- F. Withhold pain medication for headache until other manifestations resolve (it's important to address the headache promptly, especially if acetaminophen is prescribed for pain relief).

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Incorrect. Obesity is not a contraindication for acupuncture.

B. Incorrect. Hypothyroidism is not a contraindication for acupuncture.

C. Incorrect. Hypertension is not a contraindication for acupuncture.

D. Correct. Herpes zoster (shingles) involves a reactivation of the varicella-zoster virus and can cause skin lesions. Acupuncture involves the insertion of needles through the skin, which could potentially worsen the condition or lead to the spread of the virus.

A. "The client might act seductively." B. "The client is overly concerned about minor details." C. "The client exhibits impulsive behavior." D. "The client is exceptionally clingy to others."

Correct Answer is C

Explanation

A. Incorrect. Acting seductively is more characteristic of histrionic personality disorder.
B. Incorrect. Being overly concerned about minor details is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Impulsive behavior, such as reckless spending or self-harm, is a common feature of borderline personality disorder.
D. Incorrect. Being exceptionally clingy to others is not a defining feature of borderline personality disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?

Correct Answer is D

Explanation

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

Correct Answer is C

Explanation

A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?

A nurse is planning care for a client who is experiencing benzodiazepine toxicity.The nurse should plan to administer which of the following medications?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?