An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150 mL of dark brown emesis. In which order should the nurse implement these interventions? (Arrange with the highest priority intervention on top, and lowest priority intervention on bottom.)

Elevate the head of the bed.

Complete focused assessment.

Send emesis sample to the lab.

Offer PRN pain medication

Answer and Explanation

The Correct Answer is A,B,C,D

A.   Elevate the head of the bed. This intervention is the highest priority to prevent aspiration and improve the client's comfort and breathing.
B.   Complete focused assessment. A thorough assessment is necessary to gather more information about the client's condition and guide further interventions.
C.   Send emesis sample to the lab. This helps in diagnosing the underlying cause of the dark brown emesis, which could indicate a serious gastrointestinal issue.
D.   Offer PRN pain medication. Pain management is important but should be done after addressing immediate safety concerns and gathering sufficient assessment data.

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Correct Answer is B

Explanation

A. Providing counseling about contraceptives may not address the immediate concern of managing genital herpes or the risks associated with multiple sexual partners.
B. Remaining non-judgmental and assuring the client of confidentiality is crucial to establishing trust and ensuring open communication. This approach encourages the client to share accurate information about their sexual history and current concerns, which is essential for effective STI management and prevention.
C. Informing the client that complications will not result from reinfection is inaccurate and may minimize the seriousness of the STI. Genital herpes can cause recurrent outbreaks and potentially lead to complications such as neonatal herpes if transmitted to a newborn during childbirth.

D. Clarifying that all STIs are transmitted through sexual intercourse is true but does not address the client's specific situation or provide guidance on managing genital herpes and reducing the risk of transmission.

A. Collaborate with a science teacher to prepare a health lesson. B. Initiate a hearing and vision screening program for first graders. C. Prepare a presentation on how to prevent the spread of lice. D. Observe a person with type 1 diabetes mellitus self-administer a dose of insulin.

Correct Answer is B

Explanation

A. Collaborating with a science teacher to prepare a health lesson may be beneficial for health education but does not directly address secondary prevention. Secondary prevention involves early detection and intervention to prevent the progression of disease or injury.

B. Initiating a hearing and vision screening program for first graders is an example of secondary prevention. This action aims to detect any hearing or vision problems early, allowing for timely intervention and management to prevent further complications or difficulties in learning and
development.

C. Preparing a presentation on how to prevent the spread of lice may be important for promoting hygiene and preventing infestations, but it falls more under the category of health education and primary prevention rather than secondary prevention.

D. Observing a person with type 1 diabetes mellitus self-administer a dose of insulin may be related to health education or management of a chronic condition, but it does not directly address secondary prevention for school-aged children.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide?

Correct Answer is B

Explanation

Which action should the school nurse implement to provide secondary prevention for school- aged children?

Correct Answer is B

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

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

Exhibits What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?