Complete the following sentence by using the list of options.

Exhibits

The nurse should first anticipate the need to
dropdown
and then
dropdown
.

Answer and Explanation

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

Rationale:

• Obtain IV access is the first priority because the client is showing signs of hypovolemic shock low blood pressure (76/45 mm Hg), tachycardia (HR 121/min), pale mucous membranes, and diaphoresis likely due to GI bleeding. Immediate vascular access is necessary for resuscitation and fluid administration.

• Call the surgical suite to notify that the client is arriving STAT would delay essential stabilization. Transporting an unstable client without securing IV access and fluid resuscitation could worsen their condition and is unsafe.

• Place the client in a supine position with feet elevated (modified Trendelenburg) might temporarily improve venous return, but it does not address the underlying fluid deficit. It is not a substitute for urgent fluid replacement via IV access.

• Recheck the client's oxygen saturation is not a priority because the client already has a stable oxygen saturation of 98% on room air. The immediate threat is circulatory collapse, not hypoxia.

• Prepare to administer IV fluids follows IV access to treat hypotension and restore circulating volume. IV fluids help stabilize hemodynamics while awaiting further interventions like endoscopy or blood transfusion if needed.

• Transport the client for endoscopy is inappropriate at this moment because the client is hemodynamically unstable. Endoscopy is important but must be delayed until the client is stabilized.

• Check the ECG may be useful if cardiac concerns arise due to hypotension or tachycardia, but it does not take precedence over immediate circulatory support in this scenario.

• Check arterial blood gases would not provide data that immediately changes the management. The client's O2 saturation is normal, and ABGs are not needed to diagnose or treat hypovolemic shock due to GI bleeding.

Nursing Test Bank

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Correct Answer is B

Explanation

Rationale:

A. Recommend the client spend time alone in his room: Isolation can worsen depressive symptoms by reducing social interaction and support. Clients with major depressive disorder benefit more from structured, supportive environments that encourage engagement.

B. Encourage the client to use positive self-talk: Promoting positive self-talk helps challenge negative thought patterns common in depression. This cognitive-behavioral strategy can improve mood, self-esteem, and overall coping ability.

C. Offer the client low-protein snacks throughout the day: Nutritional support is important, but there is no specific reason to offer low-protein snacks for depression. A balanced diet with adequate protein may better support brain function and mood regulation.

D. Suggest the client exercise before going to bed: Regular exercise is beneficial for managing depression, but exercising before bedtime can disrupt sleep patterns. Physical activity is better scheduled earlier in the day to promote restfulness at night.

A. Clamp the chest tube every 4 hr. B. Place the client in a supine position. C. Ensure the device is kept below the level of the client's chest. D. Empty the collection chamber every 8 hr.

Correct Answer is C

Explanation

Rationale:

A. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended, as it can lead to tension pneumothorax by trapping air in the pleural space. Clamping is only done briefly and for specific reasons, such as system checks or before removal.

B. Place the client in a supine position: The supine position can impair lung expansion and hinder drainage from the pleural space. Clients with a chest tube are best positioned in semi-Fowler’s or high-Fowler’s to promote ventilation and facilitate drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the drainage system below chest level promotes gravity-assisted drainage and prevents backflow of air or fluid into the pleural space, which could compromise lung re-expansion.

D. Empty the collection chamber every 8 hr: The collection chamber is not emptied; it is replaced when full. Opening the system introduces infection risk and disrupts the closed drainage system necessary for maintaining negative pressure.

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Complete the following sentence by using the list of options. Exhibits The nurse should first anticipate the need to dropdown and then dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

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Complete the following sentence by using the list of options.

Exhibits

The nurse should first anticipate the need to
dropdown
and then
dropdown
.