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 ["A","C","D"]

Explanation

A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired.

B. Incorrect. While it's important to provide the client with some choices, too many options can be overwhelming and confusing.

C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia.

D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.

E. Incorrect. It's generally not effective to try to refute a client's delusions using logic.

Redirecting or validating their feelings might be more appropriate.

A. Evaluate the client's ability to help with repositioning. B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

Correct Answer is A

Explanation

A. Correct. Evaluating the client's ability to assist with repositioning is important to ensure safe and appropriate positioning that considers the client's capabilities and comfort.
B. Incorrect. The use of assistive devices or assistance from the nurse or other personnel may be necessary to ensure safe repositioning, especially in clients with mobility limitations.
C. Incorrect. While discussing the client's preferences is important, it may not directly relate to the immediate need for repositioning after a stroke.
D. Incorrect. Raising the side rails on both sides of the bed is important for client's safety, but it doesn't address the client's need for repositioning after a stroke.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing a client who is postoperative following orthopedic surgery.Which of the following findings should the nurse identify as an indication of paralytic ileus?

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?