Exhibits

Review H and P, nurse's note, laboratory results, and flow sheet.

Complete thee diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Small intestinal obstruction is indicated by the client’s abdominal distension, absence of bowel sounds, refusal to eat, and episodes of vomiting. The laboratory results show metabolic acidosis (HCO3 of 16 mEq), which can be associated with a bowel obstruction.
Placing a nasogastric tube helps decompress the stomach and relieve pressure caused by the obstruction, while giving IV fluids helps to prevent dehydration and electrolyte imbalances that can occur with vomiting and obstruction.
Monitoring signs and symptoms of dehydration is crucial as the client has been vomiting and may not be able to maintain adequate fluid intake. Monitoring temperature is also essential to detect any signs of infection or complications related to the obstruction.

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Correct Answer is C

Explanation

A. Observing body language and movement can provide clues about the client's pain but does not directly assess the quality of the pain experienced.
B. Identifying effective pain relief measures is important for managing pain but does not assess the quality of pain itself.
C. Asking the client to describe the pain directly assesses its quality, allowing the nurse to understand its characteristics, such as intensity, duration, and type (e.g., sharp, dull, throbbing).
D. Providing a numeric pain scale is useful for quantifying pain intensity but does not capture the qualitative aspects of the pain experience.

A. Teach a family member to administer eye drops. B. Obtain vital signs every 2 hours during hospitalization. C. Provide an eye shield to be worn while sleeping. D. Encourage deep breathing and coughing exercises.

Correct Answer is C

Explanation

A. While teaching about eye drops is important, it is not the immediate priority following eye surgery.
B. Obtaining vital signs is essential for overall recovery but is not the most immediate concern related to the eye surgery.
C. Providing an eye shield to be worn while sleeping is crucial to protect the eye after surgery, preventing accidental injury or pressure on the surgical site.
D. Encouraging deep breathing and coughing exercises is important for overall recovery but is not specific to eye surgery and does not address the immediate need for eye protection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is C

Explanation

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Correct Answer is C

Explanation

Exhibits Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?

Exhibits The nurse is preparing to set up the oxygen administration and apply the simple face mask. Which should the nurse do before applying the face mask? Select that apply.

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?