An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?

Discuss with the family about placing the client in a skilled care facility.

Determine if the client is manifesting other neurologic changes.

Request family members report when the client is left alone.

Apply a restraining device to prevent the client from self injury.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Discussing with the family about placing the client in a skilled care facility may be a consideration, but it's not the most immediate concern. Choice B rationale: Determining if the client is manifesting other neurologic changes is crucial to identify potential complications or underlying issues causing the agitation.

Choice C rationale: Requesting family members to report when the client is left alone is important for safety but doesn't address the immediate assessment of the client's condition.

Choice D rationale: Applying a restraining device to prevent the client from self-injury is not the first choice and should only be considered if there's an immediate threat to the client's safety or the safety of others.

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Correct Answer is C

Explanation

Choice A rationale: Verifying with the client that the blood was drawn is a good practice, but it might not provide immediate information about the current glucose level. The nurse needs a timely assessment to determine whether the client can safely receive the scheduled breakfast.

Choice B rationale: Checking when insulin was last administered is important, but it doesn't provide real-time information about the current glucose level. The nurse needs this information before deciding on breakfast administration.

Choice C rationale: Performing a capillary glucose test is a quick way to obtain current blood glucose levels, allowing the nurse to make an informed decision about administering the breakfast tray. This action is consistent with assessing the client's immediate status.

Choice D rationale: Giving the client the breakfast tray without knowing the current glucose level could be unsafe and against the prescribed plan of care. Assessing the glucose level is a necessary step before administering meals, especially in clients with diabetes.

A. Hepatitis A complaining of arms and legs itching. B. Rheumatoid arthritis having trouble sleeping. C. Spinal osteomyelitis with complaint of nausea. D. Right leg cast with a tingling down the leg.

Correct Answer is D

Explanation

Choice A rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice B rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice C rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice D rationale: This could indicate impaired circulation or nerve compression, which could lead to permanent damage or loss of limb if not treated promptly.

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Naxlex Comprehensive Predictor Exams

Breakfast trays have arrived on the unit, but the daily serum glucose level is not available on the chart of a client with type 1 diabetes mellitus. Which action should the nurse take?

Correct Answer is C

Explanation

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?

Correct Answer is D

Explanation

The nurse manager conducts regular audits of patient care medication records and notices that the amount of narcotic pain medications administered during the evening shift on a postsurgical unit is higher than usual. Which action should the nurse manager take first?

After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?

The nurse receives change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?

During a 24-hour electronic health record review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the previous shift. Which immediate action is best for the nurse to take?