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 B

Explanation

Choice A rationale

While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.

Choice B rationale

Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.

Choice C rationale

Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.

Choice D rationale

Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.

A. Assist the client to the bathroom. B. Have an opioid agonist at the bedside. C. Provide oral care at least twice a day. D. Assess mental status regularly. E. Monitor calcium levels. F. Screen for orthostatic hypotension.

Correct Answer is ["A","D","F"]

Explanation

Choice A rationale

Assisting the client to the bathroom is appropriate as clonazepam can cause dizziness and unsteadiness, increasing the risk of falls.

Choice B rationale

Having an opioid agonist at the bedside is not necessary for a client starting clonazepam. Clonazepam is a benzodiazepine, not an opioid.

Choice C rationale

Providing oral care at least twice a day is generally good practice for all patients, but it’s not specifically related to clonazepam use.

Choice D rationale

Assessing mental status regularly is crucial as clonazepam can cause changes in mood and behavior.

Choice E rationale

Monitoring calcium levels is not typically required for a client starting clonazepam.

Choice F rationale

Screening for orthostatic hypotension is important as clonazepam can lower blood pressure, leading to dizziness and fainting when the client stands up.

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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

Correct Answer is B

Explanation

What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

Correct Answer is ["A","D","F"]

Explanation

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

A client newly diagnosed with type 1 diabetes mellitus (DM) asks the nurse to leave the room when the nurse tries to teach self-administration of insulin injections.What should the nurse do next?

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

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection.What foods should the nurse encourage this client to eat?

Exhibits

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