Try Naxlex NCLEX-RN (Free-Trial)

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

An adult client who has a history of sleep apnea and needs help applying a continuous positive airway pressure (CPAP) before bedtime.

The parent of a child who reports the child cannot sleep because there is too much noise in the hallway.

An older adult client recently admitted from a long-term care facility who is exhibiting sundowning behaviors.

An older adult client who is anxious about an impending procedure and is worried about being unable to sleep.

Answer and Explanation

The Correct Answer is A

A.   Sleep apnea is a serious condition where the airway becomes blocked during sleep, which can lead to significant health issues, including heart problems and severe oxygen desaturation. The CPAP machine is crucial for managing sleep apnea by ensuring continuous airflow during sleep. If this client needs help applying the CPAP and does not get the assistance they need, they may experience severe complications from untreated sleep apnea.
B.   While noise in the hallway can certainly disrupt a child’s sleep and cause distress, it is not an immediate health crisis. It is important to address environmental concerns for comfort and sleep quality but this situation is less critical compared to the potential health risks associated with untreated sleep apnea.
C. Sundowning refers to increased confusion and agitation in the late afternoon or evening, which can be distressing and challenging to manage. While important, this issue is generally not as immediately life-threatening as problems related to sleep apnea or severe anxiety about a procedure.
D.   Anxiety about an upcoming procedure and difficulty sleeping are significant concerns, especially for emotional and mental well-being. However, while this client’s anxiety should be addressed to improve their comfort and preparation for the procedure, it does not present an immediate physical threat to health like the potential complications of untreated sleep apnea.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The walker should be adjusted to the client's height so that their elbows are slightly flexed when grasping the hand bars. This allows for proper weight-bearing and reduces strain on the shoulders and arms. Using a walker that is the correct height can help to prevent falls by providing better stability and support.
B. Removing the wheels from the walker would make it difficult for the client to use. The wheels are an important feature of a walker, as they allow the client to move more easily.
C. While demonstrating more coordinated movement may be helpful, it's not the most immediate action needed. Adjusting the height of the walker is a more important step to ensure the client's safety and comfort.
D. Encouraging the client to continue using the walker as observed may not be appropriate if the walker is not adjusted to the correct height. A properly adjusted walker is essential for safe and effective mobility.

A. Initiate infusion for an IV fluid bolus. B. Administer an IV antiemetic. C. Medicate with PRN IV narcotic. D. Discourage straining on stool.

Correct Answer is C

Explanation

A. While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B. Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C. The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D. This is not relevant to the client's current symptoms of severe pain and nausea.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?