Exhibits

The healthcare provider places orders to determine the cause of client symptoms.

Use the chart to indicate if the listed symptom or finding is consistent with gastroenteritis, appendicitis, or ectopic pregnancy.

Each row must have at least one, but may have more than one, response option selected.

Fever

Tachycardia

Nausea

Vomiting

Diarrhea

Answer and Explanation

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

Fever is a common symptom that can be present in gastroenteritis, appendicitis, and, less commonly, ectopic pregnancy. Tachycardia may occur in all three conditions but is more commonly associated with ectopic pregnancy, especially if there is internal bleeding. Nausea and vomiting are symptoms that can be seen in gastroenteritis and appendicitis, and occasionally in ectopic pregnancy. Diarrhea is most commonly associated with gastroenteritis.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","F","G","H"]

Explanation

A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.

A. Altered nutrition; less than body requirements. B. Activity intolerance. C. Fluid volume excess. D. Ineffective airway clearance.

Correct Answer is D

Explanation

A. Altered nutrition is a concern but is not the immediate priority.
B. Activity intolerance is expected but does not pose an immediate threat.
C. Fluid volume excess should be monitored, but ineffective airway clearance poses a more immediate risk.
D. Ineffective airway clearance is the highest priority because a flank incision can cause significant pain, leading to shallow breathing and increased risk for atelectasis or pneumonia.

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Naxlex Comprehensive Predictor Exams

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Correct Answer is ["A","F","G","H"]

Explanation

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Correct Answer is D

Explanation

Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

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A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

Exhibits According to the lab values, the client has dropdownrelated to dropdownordropdown.

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

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