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A nurse on a medical surgical unit is admitting a client from a provider's office.

Exhibits
Click to highlight the information in the Nurse's Notes and Vital Signs that should be reported to the provider.

1500:

Temperature: 39 degrees Celcius (102.2 F)

Heart rate: 122/min

Respiratory rate: 24/min

BP: 106/54 mmHg

Oxygen saturation: 95% on room air

1530:

Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.

Voiding dark, concentrated urine.

Client requesting water

Temperature: 39 degrees Celcius (102.2 F)

Heart rate: 122/min

Respiratory rate: 24/min

BP: 106/54 mmHg

Oxygen saturation: 95% on room air

Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.

Voiding dark, concentrated urine.

Client requesting water

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","H"]

Vital Signs

Temperature: 39°C (102.2°F) → fever worsened since admission (sign of possible infection).
Heart rate: 122/min → tachycardia, worsened compared to earlier.
Blood pressure: 106/54 mmHg → trending downward, may indicate fluid deficit/hypotension risk.

Nurse’s Notes

Client lethargic → worsening mental status.
Projectile vomiting → new onset, risk of dehydration and electrolyte imbalance.
Abdominal cramping → possible gastrointestinal complication.
Voiding dark, concentrated urine → sign of dehydration.
Client requesting water → excessive thirst consistent with hyperglycemia/possible hyperosmolar state.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Rationale:
A. Baked potato is low in sodium if prepared without added salt, making it safe for a client on a diuretic.
B. Milkshake is generally safe unless it contains added sodium; in most cases, it is allowed.
C. Ham is high in sodium, which is contraindicated for a client taking bumetanide, a loop diuretic, as high sodium intake can counteract the diuretic effect and worsen fluid retention.
D. Stewed tomatoes can be included if unsalted; they are generally safe in moderation.

A. Right upper quadrant B. Right lower quadrant C. Left lower quadrant D. Left upper quadrant

Correct Answer is B

Explanation

Rationale:
A. Right upper quadrant contains the liver and gallbladder; pain here is more typical of hepatobiliary disorders, not appendicitis.
B. Right lower quadrant is the correct location of McBurney’s point, found one-third of the distance from the anterior superior iliac spine to the umbilicus. Tenderness here is a classic sign of appendicitis.
C. Left lower quadrant pain is commonly associated with conditions like diverticulitis, not appendicitis.
D. Left upper quadrant contains the stomach, spleen, and pancreas tail; pain here suggests disorders of those organs, not appendicitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?

Correct Answer is C

Explanation

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

Correct Answer is B

Explanation

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client in a rehabilitation facility. Exhibits Select the common side effects of antibiotics related to gastrointestinal health

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?

A nurse is evaluating a client admitted to the emergency unit. Exhibits Which nursing interventions are appropriate for managing a patient with cirrhosis experiencing fluid volume excess?