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A nurse is reviewing the medical record of a client

Exhibits

Click to highlight below the findings that require immediate follow-up.

Body System Findings

Neurological Alert and oriented to person, place, and time; deep tendon reflexes 4+

Musculoskeletal
Generalized weakness with equal bilateral muscle strength and mild leg cramping

Respiratory : Lungs clear

Cardiovascular : Heart rate irregular, Heart rate 95/min

Gastrointestinal Bowel sounds hyperactive x 4 quadrants

Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

deep tendon reflexes 4+

Heart rate irregular

Bowel sounds hyperactive x 4 quadrants

Generalized weakness with equal bilateral muscle strength and mild leg cramping

Lungs clear

Heart rate 95/min

Alert and oriented to person, place, and time;

Answer and Explanation

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

An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is E,B,C,D,A

Explanation

First, the nurse should apply clean gloves (E) to maintain sterility and safety. Next, the nurse should disconnect the tube from the suction device (B), ensuring that the device is no longer actively working on the tube.

Before removing the tube, it is important to instill air into it (C); this helps clear any residual contents and minimizes the risk of aspiration. The nurse should then ask the client to take a deep breath (D), which helps close the epiglottis to prevent aspiration during the removal of the tube. Finally, the nurse can pinch and withdraw the tube (A), completing the process in a swift, steady motion to ensure comfort and safety for the client.

A. Return the medication to the medication cabinet. B. Notify the provider of the client's refusal. C. Document the refusal in the client's medical record. D. Inform the client of the potential consequences of their refusal

Correct Answer is D

Explanation

A. Return the medication to the medication cabinet- Returning the medication without addressing the client's concerns does not promote understanding or collaboration.
B. Notify the provider of the client's refusal- Notifying the provider is important but should come after attempting to address the client's concerns.
C. Document the refusal in the client's medical record- Documentation is necessary but should follow a discussion with the client.
D. Inform the client of the potential consequences of their refusal- The nurse should first educate the client about the risks associated with not taking their antihypertensive medication to ensure they are making an informed decision.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is E,B,C,D,A

Explanation

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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