A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?

Notify the emergency response team of the client's seizure.

Keep orienting the client to time and place until he is less confused.

Explain the postictal state that usually follows seizures.

Ask the wife to wait outside the room until the nurse can talk with her.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.

Choice B reason: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.

Choice C reason: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.

Choice D reason: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer because moderate amount of foul-smelling lochia is a sign of endometritis, which is an infection of the uterine lining that can occur after delivery. Endometritis can cause fever, pelvic pain, and uterine tenderness.

Choice B reason: Blood pressure of 122/74 mm Hg is within the normal range for a postpartum client and does not indicate an infection. However, the nurse should monitor for signs of preeclampsia or eclampsia, such as hypertension, proteinuria, headache, blurred vision, and seizures.

Choice C reason: Oral temperature of 100.2°F (37.9°C) is slightly elevated, but not necessarily indicative of an infection. A mild fever may occur within the first 24 hours after delivery due to dehydration or hormonal changes. However, if the fever persists or increases, the nurse should suspect an infection and notify the healthcare provider.

Choice D reason: White blood cell count of 19,000/mm^3 (19 x 10^9/L) is higher than the normal range, but not necessarily indicative of an infection. A leukocytosis or increased WBC count may occur as a normal response to stress or trauma during delivery. However, if the WBC count remains elevated or increases further, the nurse should suspect an infection and notify the healthcare provider.

A. Apply an allergy identification wrist band. B. Instruct the client to avoid medication containing milk and eggs. C. Enter allergy information in the client's electronic medical record. D. Ensure the client's selections from her dietary menu. E. Notify the dietary department of the client's egg intolerance.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Applying an allergy identification wrist band is an intervention that the nurse should implement, as this can alert other health care providers of the client's allergies and prevent adverse reactions. Therefore, this is a correct choice.

Choice B reason: Instructing the client to avoid medication containing milk and eggs is not an intervention that the nurse should implement, as this is not a common or relevant source of allergens for this client. This is an incorrect choice.

Choice C reason: Entering allergy information in the client's electronic medical record is an intervention that the nurse should implement, as this can ensure accurate and updated documentation of the client's allergies and facilitate communication among health care providers. Therefore, this is another correct choice.

Choice D reason: Ensuring the client's selections from her dietary menu is an intervention that the nurse should implement, as this can help avoid foods that may trigger allergic reactions or intolerance for this client. Therefore, this is another correct choice.

Choice E reason: Notifying the dietary department of the client's egg intolerance is an intervention that the nurse should implement, as this can help modify or substitute foods that contain eggs for this client. Therefore, this is another correct choice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?White Blood Cell (WBC) Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)

Correct Answer is A

Explanation

Correct Answer is ["A","C","D","E"]

Explanation

A preschool-aged child who is being tested for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the clearest indication to the nurse that the child is experiencing a reaction to toxins that are created by Streptococcal bacteria?

In caring for a client who is receiving meropenem IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?

An adult with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?