A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration, and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Administer pain medication to the first client.

Weigh the second client.

Change the dressings of both clients.

Obtain vital signs for both clients.

Answer and Explanation

The Correct Answer is A

A. Administer pain medication to the first client: Pain management is a priority, especially for a postoperative patient with a pain level of 6 out of 10. Addressing pain can improve the client’s comfort and ability to participate in other aspects of care, such as nutrition administration and mobility.

B. Weigh the second client: While important for monitoring nutritional status, weighing the client is not as urgent as managing pain for a postoperative patient.

C. Change the dressings of both clients: Dressing changes are necessary but can be scheduled after addressing the more immediate needs such as pain management for the postoperative client.

D. Obtain vital signs for both clients: While vital signs are important for assessing overall health, pain management should be prioritized to address the immediate discomfort and potential impacts on recovery.

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Correct Answer is A

Explanation

A. "I will begin upon the client's admission to the facility.": Discharge planning should start at admission to ensure that all aspects of the client's care and needs are addressed well before the discharge date.

B. "I will begin once the client's discharge order is written.": Waiting for the discharge order delays the discharge planning process and may result in insufficient preparation for the client’s needs.

C. "I will begin once the client's insurance company approves discharge coverage.": Insurance approval is important but should not delay the initiation of discharge planning, which focuses on the client's needs and readiness for discharge.

D. "I will begin 48 hr before the client's discharge.": Starting discharge planning just 48 hours before discharge may not provide enough time to address all aspects of the client’s care and ensure a smooth transition.

Correct Answer is ["2"]

Explanation

To calculate the volume to administer, we'll use the following formula:

Volume (mL) = Desired dose (mg) / Concentration (mg/mL)

In this case:

Desired dose = 50 mg
Concentration = 25 mg/mL

Plugging the values into the formula:

Volume = 50 mg / 25 mg/mL = 2 mL

=2mL

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

Correct Answer is A

Explanation

Correct Answer is ["2"]

Explanation

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to Infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing to administer medications to a client who states, "I don't want to take those drugs." Which of the following actions should the nurse take?

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?