On the second postoperative day, a client who had a colon resection is starting to eat and ambulate with assistance. Although the client has a prescription for an oral analgesic, they request that the PCA containing morphine be continued for one more day due to fear of pain. Which intervention is most important for the nurse to implement?

Measure urinary output to ensure renal functioning.

Administer the oral analgesic medication an hour before discontinuing the PCA pump.

Monitor for a depressed respiratory rate.

Teach about the need to progress to a high-fiber diet.

Answer and Explanation

The Correct Answer is B

Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.

Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.

Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.

Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason: Offering supplemental formula feedings may not be the best initial approach for inverted nipples as it could lead to nipple confusion and interfere with breastfeeding.

Choice B reason: While teaching about the use of a breast pump is helpful for expressing milk, it does not directly address the issue of latching with inverted nipples.

Choice C reason: A breast shield can be beneficial for mothers with inverted nipples as it can help draw out the nipple, allowing the baby to latch on more effectively.

Choice D reason: Using ice on the areola is not a recommended practice for addressing inverted nipples as it can cause discomfort and is not a reliable method for improving latch.

A. Move the client to a private room, keep the door closed, and initiate droplet precautions. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Assist the client to recall everyone possibly exposed since the onset of symptoms. D. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

Correct Answer is A

Explanation

Choice A reason: This is the most immediate and important action to take to prevent the potential spread of COVID-19, especially in a healthcare setting where there is a risk of infecting others.

Choice B reason: While placing the swab in a biohazard bag is a standard procedure, it is not as critical as isolating the patient to prevent transmission.

Choice C reason: Assisting the client to recall contacts is important for contact tracing, but it is secondary to immediate infection control measures within the clinic.

Choice D reason: Educating the client on preventive measures is important, but it does not take precedence over immediate actions to prevent the spread of infection in the clinic.

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Naxlex Comprehensive Predictor Exams

A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is C

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

Patient Data Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

Patient Data Exhibits The nurse reviews the client data. What discharge education should the nurse provide? Select all that apply.

After a partial gastrectomy, in addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform to prevent respiratory complications?

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.