Exhibits

The nurse is planning care for the client.

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.

Answer and Explanation

The Correct Answer is []

Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.

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Correct Answer is B

Explanation

A. The hospital pharmacist can provide valuable information about medication dosages and potential discrepancies, but the primary source for clarification about the prescribed treatment plan is the healthcare provider who issued the prescription.
B. The healthcare provider should be contacted first to clarify the dosage discrepancy. The provider can confirm whether the dosage is correct or if there was an error in the prescription. This ensures that any potential issues are addressed by the person responsible for the treatment plan.
C. A medication reference guide is useful for checking normal dosages, but it does not clarify if a specific prescription is appropriate for the client’s condition. The provider’s confirmation is necessary for resolving discrepancies.
D. The nursing unit charge nurse may be consulted for additional guidance but is not the primary resource for verifying or resolving prescription dosages.

A. Paper mask and gown. B. A sputum specimen. C. The nurse's stethoscope. D. Bed linens.

Correct Answer is A

Explanation

A. Paper masks and gowns used for isolation precautions should be placed in a designated biohazard bag before removal from the room. These items are considered contaminated and must be disposed of according to infection control protocols.
B. A sputum specimen should be placed in a sealed, labeled container before being transported to the lab, not in a biohazard bag for disposal.
C. The nurse's stethoscope should be disinfected but does not need to be disposed of unless it is single-use.
D. Bed linens are typically placed in a laundry bag specifically designated for contaminated linens, not in a biohazard bag.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Correct Answer is A

Explanation

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

During the prodromal stage of an infection, which is the priority nursing intervention?

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