Exhibits

The nurse has reviewed the laboratory results and flow sheet.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse recognizes that the client has
dropdown
incontinence and
dropdown
which may be caused by benign prostate hyperplasia.

Answer and Explanation

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

Bladder retention: The client reports increased urinary urgency and frequency, waking at night to void, and instances of incontinence. These symptoms are consistent with bladder retention, where the bladder does not empty completely, often seen in benign prostatic hyperplasia (BPH).

Overflow incontinence: This type of incontinence occurs when the bladder is full, and small amounts of urine leak out due to an inability to empty the bladder properly, commonly associated with BPH.

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Correct Answer is ["B","D","E"]

Explanation

A. Standard precautions are important, but VRE requires contact precautions due to its highly transmissible nature. A mask is not specifically required unless there are respiratory symptoms.

B. Contact precautions are essential for preventing the spread of VRE and should be instituted for staff and visitors.

C. A low bacteria diet is not necessary for VRE infections; it is more relevant for immunocompromised patients.

D. Monitoring the white blood cell count helps assess the infection's progression and the body's response.

E. Sending wound drainage for culture and sensitivity is crucial for identifying the specific pathogen and determining appropriate antibiotic treatment.

A. Administer 2 mg of diazepam intravenously. B. Induce paralysis. C. Apply cooling blankets. D. Apply 1 L/min oxygen. E. Ensure that the antidepressant medication is discontinued

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

Explanation

Diazepam is a benzodiazepine that can be effective in managing symptoms of serotonin syndrome, including agitation and myoclonus. It can help reduce muscle rigidity and provide sedation.

Inducing paralysis is not appropriate in this scenario. The patient’s symptoms suggest serotonin syndrome or another type of stimulant intoxication, and paralysis could worsen the situation or mask underlying symptoms.

The patient has a high fever (102°F or 38.8°C) and significant diaphoresis. Cooling blankets can help manage hyperthermia and reduce body temperature.

The patient’s oxygen saturation is 97% on room air, indicating adequate oxygenation. There is no immediate need for supplemental oxygen at this time.

If the patient is suspected to have serotonin syndrome, which can be triggered by the use of certain antidepressants (particularly SSRIs), discontinuing the offending medication is crucial.

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Naxlex Comprehensive Predictor Exams

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

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

Explanation

Patient Data Exhibits Which 2 prescriptions should the nurse complete first?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Patient Data Exhibits Complete the 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.

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?