Exhibits

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)

Start the prescribed antibiotic

Discontinue nasogastric tube

Reinforce preoperative teaching

Provide the client with ice chips

Answer and Explanation

The Correct Answer is C

A. Start the prescribed antibiotic: There is no indication of infection in the current clinical findings; antibiotics are typically used to treat bacterial infections, which are not yet evident.
B. Discontinue nasogastric tube: The nasogastric tube should remain in place as it helps relieve the symptoms of small bowel obstruction (e.g., vomiting and bloating).
C. Reinforce preoperative teaching: The client is on NPO status, which may suggest preparation for a surgical intervention to address the obstruction. Reinforcing preoperative teaching would be beneficial to ensure the client understands the procedure.
D. Provide the client with ice chips: The client is on NPO status, and consuming food or fluids is contraindicated due to the potential for aspiration or worsening of the condition (e.g., bowel obstruction or pancreatitis).

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Correct Answer is C

Explanation

A. "It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.
B. "I will perform breast exams every other month": BSE should be done monthly to detect any changes early.
C. "It is common for one breast to be larger than the other." Slight asymmetry between breasts is normal and not a cause for concern unless there is a sudden change.
D. "I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.

A. Unable to repeat the names of three common objects the nurse names. B. Unable to answer a judgment question correctly. C. Unable to remember their adult children's names. D. Unable to remain fully awake while answering questions.

Correct Answer is D

Explanation

A. "Unable to repeat the names of three common objects the nurse names.": This indicates possible short-term memory issues but is less critical than a reduced level of consciousness.
B. "Unable to answer a judgment question correctly.": Poor judgment is less immediately concerning compared to reduced consciousness.
C. "Unable to remember their adult children's names.": Long-term memory loss is not as urgent as changes in consciousness or neurological status.
D. "Unable to remain fully awake while answering questions.": This finding suggests a potential decline in neurological status, such as increased intracranial pressure or a brain injury, and is the priority.

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Exhibits Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Correct Answer is D

Explanation

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A nurse is reinforcing teaching about meal planning with a client who has hypertension. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

Exhibits

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)