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 C

Explanation

Choice A rationale

While altered taste sensation can occur with radiation treatment, it’s not the most likely reason for an imbalance in nutritional intake in this scenario.

Choice B rationale

Fatigue can be a side effect of radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.

Choice C rationale

Pain during eating is the most likely cause of imbalanced nutritional intake in this scenario. The patient’s laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the patient from eating, leading to decreased nutritional intake.

Choice D rationale

Nausea can occur with radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.

A. She had difficulty breathing during a hike B. She experienced a severe allergic reaction C. She had a panic attack D. She fainted at home .

Correct Answer is A

Explanation

Choice A rationale

The patient’s history indicates that she had difficulty breathing during a hike. This event led her to the emergency department. Difficulty breathing during physical activity such as hiking can be a symptom of an asthma exacerbation.

Choice B rationale

While severe allergic reactions can cause difficulty breathing, the patient’s history does not indicate that she experienced an allergic reaction prior to her emergency department visit.

Choice C rationale

Panic attacks can cause symptoms such as rapid heart rate, sweating, and shortness of breath. However, the patient’s history does not indicate that she had a panic attack prior to her emergency department visit.

Choice D rationale

Fainting, or loss of consciousness, can be caused by various conditions, including dehydration, low blood sugar, and heart problems. However, the patient’s history does not indicate that she fainted prior to her emergency department visit.

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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 patient undergoing radiation treatment for laryngeal cancer has developed xerostomia and mucositis, leading to an imbalance in nutritional intake.What is the most likely reason for this issue?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

Which client statement or behavior is most likely associated with their current condition?

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity.Which test should the nurse schedule the client for evaluation of the symptoms?

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Exhibits

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