Try Naxlex NCLEX-RN (Free-Trial)

Patient Data

Exhibits

Click to highlight the findings that indicate the client is stable for discharge.

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment findings

Neurological Alert and oriented times 4.

Cardiovascular WNL.

Respiratory WNL.

Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.

Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.

Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.

The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning

She has tolerated fluids throughout the night with no nausea or vomiting

Alert and oriented times 4

Voided twice throughout night, urine clear amber in appearance

Musculoskeletal Reported chronic knee pain

No bowel movement but the client is passing gas

Sequential devices are in place for venous thromboembolism

4 abdominal incisions from laparoscopic procedure sealed with surgical glue

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment findings

Neurological Alert and oriented times 4.
Cardiovascular WNL.
Respiratory WNL.
Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.
Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.
Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Measuring body temperature is a standard procedure but not directly related to monitoring for adverse effects of prasugrel, which primarily include bleeding complications.

Choice B reason: Assessing skin turgor is generally used to evaluate hydration status and is not specific to prasugrel's adverse effects.

Choice C reason: Checking for pedal edema can indicate heart failure or vascular problems but is not a direct indicator of prasugrel's adverse effects.

Choice D reason: Observing the color of urine is important as prasugrel can cause significant and sometimes fatal bleeding. Dark or bloody urine may be an early indicator of such bleeding.

A. Mucous strings floating in the drainage. B. Red edematous stomal appearance. C. Stomal output of 40 mL in the last hour. D. Liquid brown drainage from the stoma.

Correct Answer is D

Explanation

Choice A reason: Mucous strings in the drainage are normal as mucus is produced by the intestine, which is now part of the urinary diversion.

Choice B reason: A red edematous stomal appearance can be expected postoperatively as part of the normal healing process.

Choice C reason: Stomal output of 40 mL in the last hour is within the normal range for postoperative urinary output.

Choice D reason: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer is D

Explanation

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding no understanding of the education given.

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

Patient Data Exhibits The nurse reviews new data. Which 5 nursing interventions are indicated for this client?

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?