Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow-up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep at night.
Which intervention is most important for the nurse to implement?

Ask the spouse if the client seems to be depressed.

Tell the spouse to wait outside so the client can be assessed for depression.

Explain that depression often occurs after a life-threatening experience.

Encourage the client to further describe his feelings.

Answer and Explanation

The Correct Answer is D

A.   Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B.   While privacy is important, the spouse can often provide additional valuable information.
C.   Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D.   Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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Correct Answer is A

Explanation

A. Increasing fluid intake helps thin pulmonary secretions, making them easier to expectorate and is most directly related to clearing the airway.
B. Providing frequent rest periods is important but does not directly clear the airway.

C. Administering O2 addresses hypoxia but does not clear secretions.

D. Semi-Fowler's position helps with breathing but does not specifically address thick secretions.

A. Report when hematuria becomes pink tinged. B. Restrict all physical activities. C. Use the incentive spirometer. D. Monitor urinary stream for decreased output.

Correct Answer is D

Explanation

A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is A

Explanation

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

Correct Answer is D

Explanation

Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol abuse. Which medication should the nurse administer to prevent the development of Wernicke's syndrome?

A client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client?

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?