An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.

He hasn’t had a bowel movement in 7 days, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse perform the following interventions? Arrange from highest to lowest priority.

Complete a focused assessment.

Offer PRN pain medication.

Send the emesis sample to the lab.

Elevate the head of the bed.

Answer and Explanation

The Correct Answer is A,D,B,C

Complete a focused assessment: The first step in managing a patient with abdominal pain and other symptoms is to perform a comprehensive assessment. This will help identify the cause of the symptoms and guide subsequent interventions.
Offer PRN pain medication: Once the immediate risks have been addressed, managing the patient’s pain is a priority. However, the choice of pain medication will depend on the results of the assessment.
Send the emesis sample to the lab: Sending the emesis sample to the lab can provide valuable information about the cause of the patient’s symptoms. However, this is not as urgent as the other interventions.
Elevate the head of the bed: Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has vomited. This should be done as soon as possible.

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Correct Answer is A

Explanation

Choice A rationale

The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.

A. Review H and P, nurse’s notes, flow sheet, and orders. B. Call for a chest x-ray. C. Hypocalcemia. D. Monitor respiratory rate.

Correct Answer is C

Explanation

Choice A rationale
Reviewing the history and physical (H&P), nurse’s notes, flow sheet, and orders is a standard part of nursing care for any patient. However, in the case of a 3-week-old infant who has had a seizure, this action alone would not directly address the condition the infant is most likely experiencing.

Choice B rationale
While calling for a chest x-ray could be part of the diagnostic process for certain conditions, it is not typically the first action taken in response to a seizure in an infant.

Choice C rationale
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.

Choice D rationale

Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure. However, it does not specify the condition the infant is most likely experiencing.

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Naxlex Comprehensive Predictor Exams

A client with influenza requires assistance in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

When providing nursing care for a client after a gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?

The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

An adult patient visits the clinic expressing concern about a lump that appeared on their neck about a week ago. Upon examination, the nurse finds a large, non-tender, hardened left subclavian lymph node without any overlying tissue inflammation. What could these findings indicate?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.