Exhibits here

The nurse is implementing the plan of care.

For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.

Answer and Explanation

The Correct Answer is []

Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.

Cardiovascular

Monitor vital signs continuously

The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.

Provide warmth

Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.

Respiratory

Assess lung sounds

The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.

Chest x-ray

Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.

Nursing Test Bank

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Correct Answer is B

Explanation

A. These laboratory values will provide data to anticipate delays in growth and development.
While abnormal results from these tests could indicate potential developmental issues, the primary purpose of the screening is not to predict delays in growth and development but to identify metabolic deficiencies.

B. This is a routine blood test required by law to screen for metabolic deficiencies.
This is the correct answer. Neonatal screening, including tests for T4 and TSH, is a standard practice mandated by law in many regions to identify metabolic deficiencies such as congenital hypothyroidism early on, ensuring prompt treatment to prevent serious health issues.

C. Dosages for thyroid replacement therapy will be determined by this test.
This explanation might be applicable if a deficiency is detected, but it is not the primary reason for conducting the initial screening. The primary purpose is to identify whether there is a need for treatment.

D. This technique is used for early detection of intellectual disabilities.
Although untreated metabolic deficiencies like congenital hypothyroidism can lead to intellectual disabilities, the primary goal of the screening is to detect and treat these deficiencies before they can cause such problems.

A. Erythrocytes, hemoglobin, and hematocrit. B. Serum potassium, calcium, and phosphorus. C. Blood pressure, heart rate, and temperature. D. Leukocytes, neutrophils, and thyroxine.

Correct Answer is B

Explanation

A. While monitoring erythrocytes, hemoglobin, and hematocrit is important in clients with ESRD due to the risk of anemia associated with kidney dysfunction, it is not the primary focus of monitoring for ESRD.

B. Clients with ESRD often experience electrolyte imbalances, including hyperkalemia (high potassium), hypocalcemia (low calcium), and hyperphosphatemia (high phosphorus). Monitoring these electrolyte levels is crucial to prevent complications such as cardiac arrhythmias, bone
disease, and soft tissue calcifications.

C. While blood pressure, heart rate, and temperature are essential vital signs to monitor in all clients, they are not specific laboratory tests for monitoring ESRD. However, blood pressure monitoring is particularly important in ESRD due to the increased risk of hypertension and its associated complications.

D. Monitoring leukocytes, neutrophils, and thyroxine levels is not typically a primary concern in clients with ESRD. Leukocyte and neutrophil levels may be monitored to assess for signs of infection, but they are not specific to ESRD. Thyroxine levels are typically monitored in clients with thyroid disorders, not ESRD.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

Correct Answer is B

Explanation

Which laboratory test results should the nurse monitor in a client who has end-stage renal disease (ESRD)?

Correct Answer is B

Explanation

An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?

Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

To auscultate for a carotid bruit, the nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location.)

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?