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Exhibits
The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Bone misalignment

Decreased range of motion

Left arm that is cool to touch

Swelling at the site of injury

Blood pressure of 136/90 mm Hg

Intense pain reported by client

Oxygen saturation 95% on room air

Answer and Explanation

Correct Answer : A,B,C,D,F

A. Bone misalignment - The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B. Decreased range of motion - The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C. Left arm that is cool to touch - Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D. Swelling at the site of injury - Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E. Blood pressure of 136/90 mm Hg - While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F. Intense pain reported by client - The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G. Oxygen saturation 95% on room air - While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

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Correct Answer is D

Explanation

Choice A rationale

Limiting activity for a day or two after returning home is a correct understanding. After a thoracentesis, it’s recommended to limit activity for a day or two to allow the body to recover.

Choice B rationale

Anticipating a stinging feeling during needle insertion is a correct understanding. The patient will feel a stinging sensation when the local anesthetic is injected.

Choice C rationale

Preparing to sit forward with arms propped on a table is a correct understanding. This position helps to expand the space between the ribs, making it easier for the doctor to access the pleural space.

Choice D rationale

Expecting a persistent cough after the procedure indicates a need for additional education. While a mild cough immediately after the procedure is normal, a persistent cough could indicate a complication such as a pneumothorax.

A. Instruct the patient that it is important to reduce the dose of the medication gradually. B. Advise the patient to stop taking the medication immediately. C. Encourage the patient to obtain a prescription for a benzodiazepine antagonist. D. Discuss with the patient that there may be a need for additional sleep if the feeling of fatigue is present the next day.

Correct Answer is A

Explanation

Choice A rationale

Instructing the patient that it is important to reduce the dose of the medication gradually is the best course of action. Temazepam is a benzodiazepine, and abrupt discontinuation can lead to withdrawal symptoms, which can be severe and include seizures. Therefore, it’s crucial to taper off the medication under the supervision of a healthcare provider.

Choice B rationale

Advising the patient to stop taking the medication immediately is not recommended due to the risk of withdrawal symptoms.

Choice C rationale

Encouraging the patient to obtain a prescription for a benzodiazepine antagonist is not typically the first line of action when discontinuing temazepam.

Choice D rationale

Discussing with the patient that there may be a need for additional sleep if the feeling of fatigue is present the next day is not directly addressing the issue. The patient’s feelings of being “hungover” are likely due to the effects of the medication, not a lack of sleep.

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Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an outpatient thoracentesis.Which statement made by the client indicates a need for additional education?

Correct Answer is D

Explanation

A patient taking temazepam informs you, the nurse, of plans to quit taking the medication due to feelings of being “hungover” the next day.What action should you implement?

Correct Answer is A

Explanation

An elderly patient with osteoarthritis is experiencing increased pain and stiffness in their right knee.What pathological condition should the nurse identify as the cause of these symptoms?

A patient with metastatic cancer who was taking hydromorphone orally at home is now receiving the medication intravenously while in the hospital.To evaluate if the patient is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

A patient is receiving linezolid IV for nosocomial pneumonia.Which assessment finding is most important for the nurse to report to the healthcare provider?

A patient has been prescribed 1 L of Lactated Ringer’s IV to be infused over a 12-hour period. The IV administration set delivers 15 gtt/mL. What should be the infusion rate in gtt/min? (Provide a numerical value only. If rounding is required, round to the nearest whole number.)

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

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

Exhibits
The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.