A nurse on a step-down unit is admitting a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first
dropdown
followed by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for correct choices:

Apply oxygen via nasal cannula: The client’s oxygen saturation levels of 87–88% on room air indicate moderate to severe hypoxemia, requiring immediate correction. Since the client has a history of COPD and is post-MI, improving oxygenation is essential to reduce myocardial workload and prevent further ischemia or respiratory distress.
Initiating a consult for cardiac rehabilitation: Once the client's immediate needs are stabilized, early initiation of cardiac rehabilitation is appropriate. This supports physical recovery, promotes lifestyle changes like smoking cessation and exercise, and reduces future cardiac risk.

Rationale for incorrect choices:

Administer a second dose of nitroglycerin: The client’s chest pain has resolved following the initial dose, so there is no current indication to give a second dose. Re-administering nitroglycerin unnecessarily can lead to hypotension or reflex tachycardia, especially risky in a post-MI patient.
Request a prescription for a PRN anxiolytic: The client has already been prescribed alprazolam 0.5 mg three times daily, and their anxiety has improved. Requesting an additional anxiolytic is unnecessary at this point and does not address the more urgent issue of low oxygen saturation.
Requesting a prescription for a WBC count: There are no signs or symptoms of infection such as fever, chills, or elevated WBC to justify this request. The focus should remain on the client’s cardiopulmonary status and rehabilitation rather than diagnostics that are not clinically indicated.
Administering a bolus of fluids: There is no clinical indication of fluid volume deficit, hypotension, or dehydration. Administering fluids to a post-MI patient with COPD may lead to fluid overload, pulmonary edema, or increased myocardial strain.

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Correct Answer is B

Explanation

Rationale:

A. Refer to the hallucinations as if they are real: Acknowledging hallucinations as real reinforces the client’s delusions and may worsen their psychosis. The nurse should avoid validating the hallucinations while still responding with empathy and support.

B. Ask the client directly what they are hearing: Directly asking helps assess the content, intensity, and risk associated with the hallucinations. It also opens therapeutic communication and enables the nurse to determine if the client poses a danger to themselves or others.

C. Avoid eye contact with the client: Avoiding eye contact can hinder trust and communication. Establishing a calm and respectful presence, including appropriate eye contact, supports rapport and promotes client engagement.

D. Encourage the client to lie down in a quiet room: While reducing external stimuli can help manage hallucinations, isolating the client without first assessing the hallucination’s content may not be appropriate. This action also doesn’t address the client's perception or emotional needs directly

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for Correct Choices:

Endometritis: Endometritis is a common postpartum infection of the uterine lining, often following cesarean birth, especially with risk factors like prolonged rupture of membranes and anemia. Clinical features include uterine tenderness, foul-smelling lochia, and fever, all of which are present in this case.
Uterus and lochia assessment: A uterus that is tender and slightly elevated, with moderate dark brown, malodorous lochia, is a hallmark of endometritis. The boggy fundus that firms with massage also suggests poor involution, frequently associated with infection.

Rationale for Incorrect Choices:

Mastitis: While the client reports breast discomfort, mastitis typically presents with unilateral breast pain, localized redness, and flu-like symptoms. The findings here are more consistent with engorgement than with infectious mastitis.
Pneumonia: The client has no respiratory distress, productive cough, or abnormal lung sounds (only slightly diminished bases), and oxygen saturation is normal. These signs are insufficient to support pneumonia.
Fever: Although fever is present (38.2°C), it is a nonspecific symptom that could occur with any postpartum infection or inflammation. It supports infection but does not localize the source as definitively as the uterine and lochia findings.
WBC count: The elevated WBC count (33,000/mm³) indicates infection or inflammation, but again, it is nonspecific. It supports the diagnosis but does not point solely to endometritis without clinical context from the uterus and lochia.

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A nurse on a step-down unit is admitting a client. Exhibits Complete the following sentence by using the lists of options. The nurse should first dropdown followed by dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse on a postpartum unit is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is most likely experiencing by the client's dropdown as evidenced by the client’s dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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A nurse on a step-down unit is admitting a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first
dropdown
followed by
dropdown
.