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Exhibits

Click to highlight the findings that indicate the client is stable for discharge.

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning.

She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4. Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

ambulated 100 yards (91 meters) last night and 200 yards

pain rating of 2

tolerated fluids

Alert and oriented times 4

Voided twice

Respiratory WNL

Cardiovascular WNL

no nausea or vomiting

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4.

Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

Nursing Test Bank

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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 B

Explanation

A. A rapid, irregular heart rate (e.g., atrial fibrillation) is common in mitral valve stenosis due to atrial enlargement but does not necessarily require immediate intervention unless it leads to severe symptoms like syncope or stroke.

B. Blood-tinged sputum could indicate pulmonary edema or pulmonary hypertension, both of which are serious complications of mitral valve stenosis. This finding warrants immediate intervention as it may signify acute heart failure or other critical complications requiring prompt treatment.

D. Swollen feet and ankles are common signs of fluid retention in heart failure, but they do not require immediate intervention compared to the potential complications of atrial fibrillation.

A. Have the client breathe into a paper bag. B. Ask the client to take short, rapid breaths. C. Instruct the client in pursed lip breathing. D. Increase oxygen to three L/minute.

Correct Answer is C

Explanation

A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease
experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote
relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is B

Explanation

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?

Correct Answer is C

Explanation

Exhibits What should the nurse include in post discharge care education? Select all that apply.

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A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA. The client's parent is insisting to know the laboratory test results. Which is the best response for the nurse to provide?

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula is currently short of breath. Which action should the nurse take?

A client is being discharged home after being treated for heart failure (HF. Which instruction should the nurse include in this client's discharge teaching plan?

A client receives a prescription for loratadine suspension 10 mg PO once a day. The bottle is labeled, "Loratadine for Oral Suspension, 5 mg per 5 mL." How many teaspoons should the nurse instruct the client to take? (Enter numerical value only.)

Exhibits After the physician orders the echocardiogram, the nurse provides education to the parents on the procedure. For each statement, click to indicate whether the statement by the parents indicate understanding or no understanding. Each row must have only one response option selected.