A nurse on a medical unit is admitting a client.

Exhibits

Click to highlight the findings that should be reported to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

Day 1, 1600:

Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."

States they are not able to sleep well on their back at night because of difficulty breathing.

Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.

Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.

Client reports gaining 10 pounds in the past month.

Reports history of type 2 diabetes mellitus and hypertension.

Heart rate 130/min

ECG monitor showing sinus tachycardia

edema

Breathing rapid and shallow. Crackles

gaining 10 pounds in the past month.

Answer and Explanation

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

Correct answers:

Nurses Notes Day 1, 1600:
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 150/min, ECG monitor showing sinus tachycardia, 5, auscultated. Lower extremity edema noted, 2+ bilaterally. Radial and pedal pulses 1 bilaterally. Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining "10 pounds in the past month."

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Correct. Providing the client with a one-week supply of insulin syringes ensures they have the necessary equipment to administer insulin independently at home. This supports the client's independence while managing their diabetes.
B. Incorrect. While home health visits may be appropriate for some clients with diabetes, arranging daily visits may not be necessary for an independent client who is capable of managing their condition on their own.
C. Incorrect. Notifying the family of the client's health status may be appropriate in certain situations, but it is not essential for an independent client who is capable of managing their diabetes independently.
D. Incorrect. While joining a diabetic support group can be beneficial for many individuals with diabetes, it may not be necessary for all clients, especially those who are independent and prefer to manage their condition on their own.

A. Children whose parents have college degrees B. Children who were born after 38 weeks of gestation C. Children whose parents are married D. Children who live in crowded homes

Correct Answer is D

Explanation

A. Children whose parents have college degrees may have more access to resources and support systems, potentially reducing the risk of physical abuse.
B. Children who were born after 38 weeks of gestation do not inherently have an increased risk of physical abuse based solely on gestational age at birth.
C. Children whose parents are married may have more stability in their family environment, potentially reducing the risk of physical abuse.
D. Children who live in crowded homes may experience increased stress and tension, leading to a higher risk of physical abuse due to the potential for conflict and limited space.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with developing a discharge plan for a client who has a new diagnosis of diabetes mellitus. The client is independent and lives alone. Which of the following interventions should the nurse plan to include?

Correct Answer is A

Explanation

A nurse is assisting in the development of an in-service for staff members about physical abuse of children. Which of the following children are at an increased risk for physical abuse?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?

A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea?

A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?

A nurse is reinforcing teaching about home safety with the parent of an 8-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take?

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

A nurse administered an IM injection to a client. Which of the following actions should the nurse take to reduce the risk of a needlestick injury?