Exhibits

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Check capillary refill on bilateral upper extremities.

Administer ondansetron 4 mg IV.

Inspect the bandage for drainage.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities. - Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV. - Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage. - Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

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Correct Answer is D

Explanation

Choice D rationale

In a patient with severe ulcerative colitis who has undergone surgery for a fistula repair, replacing fluids IV based on intake and output is the most important intervention to include in the plan of care. This is because patients with ulcerative colitis often experience significant fluid and electrolyte imbalances due to diarrhea and other gastrointestinal losses. Following surgery, these imbalances can be further exacerbated by factors such as fasting, surgical stress, and the use of certain medications. Therefore, careful monitoring of fluid and electrolyte balance, and appropriate IV fluid replacement, is crucial to prevent complications such as dehydration, electrolyte imbalances, and renal dysfunction.

A. Nitroglycerin. B. Aspirin. C. Morphine. D. Heparin.

Correct Answer is A

Explanation

Choice A rationale

Nitroglycerin is a medication that is commonly used to treat chest pain or angina. However, it is contraindicated in patients who have taken sildenafil (Viagra) within the last 24 hours due to the risk of severe hypotension, or low blood pressure. Sildenafil is a type of medication known as a phosphodiesterase-5 (PDE5) inhibitor, which works by relaxing the muscles in the walls of blood vessels. Nitroglycerin also works by relaxing blood vessels, so the combination of these two medications can cause a dangerous drop in blood pressure.

Choice B rationale

Aspirin is not typically withheld in patients experiencing chest pain. It is often given to patients who are suspected of having a heart attack because it works by preventing blood clots from forming and blocking the blood vessels of the heart.

Choice C rationale

Morphine is often administered to patients experiencing severe chest pain to help relieve the pain and reduce the workload of the heart. It is not typically withheld unless the patient has a known allergy or other contraindication.

Choice D rationale

Heparin is a blood thinner that is often administered to patients who are suspected of having a heart attack to prevent further blood clots from forming. It is not typically withheld unless the patient has a known allergy, other contraindication, or is at high risk of bleeding.

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Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is D

Explanation

A patient arrives at the emergency department experiencing chest pain after taking sildenafil.Based on the patient’s history, which medication should the nurse withhold?

Correct Answer is A

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management.Which response by the client indicates understanding?

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

The nurse is preparing a client for an outpatient thoracentesis.Which statement made by the client indicates a need for additional education?

The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

Exhibits

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.