Exhibits

The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.

Complete the following sentence by choosing from the lists of options.

Based on the information collected, the client is likely experiencing
related to

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure

Rationale

The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.

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Correct Answer is C

Explanation

A. While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B. These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C. Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D. Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

A. Client's breath sounds are clear to auscultation bilaterally. B. Client exhibits a frequent productive cough. C. Client demonstrates proper use of an incentive spirometer. D. Client reports using the incentive spirometer every hour while awake.

Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Correct Answer is C

Explanation

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is A

Explanation

The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?

A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?