A nurse is reviewing the medical record of a client.

Exhibits

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+

Generalized weakness

mild leg cramping

Lungs clear

Heart rate irregular

Bowel sounds hyperactive x 4 quadrants

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Deep Tendon Reflexes 4+: This indicates hyperreflexia, which can be associated with electrolyte imbalances, particularly magnesium deficiency, or central nervous system issues. In this context, the client has a low magnesium level (0.7 mEq/L), which can cause neuromuscular irritability and potentially dangerous complications.

Generalized Weakness and Mild Leg Cramping: While muscle strength is reported as equal, the generalized weakness and cramping suggest possible electrolyte imbalances or neurological issues. The combination with low magnesium levels raises concern for further complications.

Heart Rate Irregular: An irregular heart rate can indicate potential cardiac issues, especially in the context of electrolyte imbalances such as hypomagnesemia and the use of hydrochlorothiazide, which can contribute to electrolyte disturbances.

Bowel Sounds Hyperactive x 4 Quadrants: Although hyperactive bowel sounds can be associated with various conditions, in this case, they may be linked to the client's history of vomiting and possible electrolyte imbalance, warranting follow-up to ensure appropriate management of gastrointestinal symptoms.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Asking the client to explain her feelings shows empathy and encourages open communication. It allows the nurse to understand the client's concerns and address them appropriately.

B. Requesting family participation may be helpful, but it does not address the client’s specific feelings of reluctance.

C. While explaining the importance of participation can be beneficial, it may not address the client's emotional response or specific concerns.

D. Simply telling the client it is safe to touch her ostomy does not address her reluctance or provide emotional support.

A. Grasp the outermost flap of the sterile kit while opening away from the body. B. Open the innermost lower flap of the sterile kit while standing away from the sterile field. C. Open each side flap of the sterile kit individually while pulling to the side. D. Prepare a dry work surface above the waist level. E. Open the outside cover of the sterile kit and remove the dust cover.

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

Explanation

Begin by setting up a clean, dry surface above waist level to ensure sterility (Step D). Remove the dust cover and set up the sterile kit (Step E). Open the sterile kit's flaps in order, starting with the outermost (Steps A and C), and finally the innermost flap (Step B) while keeping distance to prevent contamination.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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

Explanation

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

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