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Patient Data

Exhibits

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.

The client reports he was able to sleep through the night

continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers

The client reports mild nausea and has no desire to eat breakfast

There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage

The left arm is warm to touch

The client's left shoulder and collarbone are symmetric.

Answer and Explanation

The Correct Answer is ["A","E","F"]

Rationale for Correct Choices:

The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.

Rationale for Incorrect Choices:

Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.

Nursing Test Bank

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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 {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Refrain from sharing towels and razors with others: Prevents transmission of bacteria that can enter through minor skin breaks and cause cellulitis. Maintaining personal hygiene items reduces the risk of reinfection or spreading pathogens to others.

• Complete full course of antibiotic therapy: Promotes healing by ensuring that the bacterial infection is fully eradicated. Stopping antibiotics prematurely can lead to treatment failure, recurrence, or development of resistant organisms.

• Wash hands before and after touching open wounds including bug bites: Prevents future cellulitis by reducing the likelihood of introducing bacteria to compromised skin. Proper hand hygiene is a key preventive measure for both the client and caregivers.

• Shower daily with antibacterial soap: Helps prevent future cellulitis by reducing bacterial load on the skin. Regular cleansing is particularly important in clients with diabetes or peripheral vascular disease, who are more prone to skin infections.

• Eat foods which contain protein and vitamin C: Promotes healing by supporting tissue repair and immune function. Adequate nutrition enhances wound healing, reduces recovery time, and strengthens defenses against infection.

A. Note and report the client's food and liquid intake during meals and snacks. B. Assess the client for weakness and fatigue. C. Report any client mention of pain or discomfort. D. Weigh the client and report any weight gain. E. Evaluate the client for sleep disturbances.

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

Explanation

A. Note and report the client's food and liquid intake during meals and snacks: UAPs can monitor and document intake and output, then report to the nurse for evaluation. This is within their role.

B. Assess the client for weakness and fatigue: Assessment requires nursing judgment and interpretation of findings, which cannot be delegated to UAPs.

C. Report any client mention of pain or discomfort: UAPs may report observations or client statements to the nurse. The nurse is responsible for further assessment and management.

D. Weigh the client and report any weight gain: Daily weights and reporting results are appropriate UAP tasks, as they are routine and measurable without requiring clinical judgment.

E. Evaluate the client for sleep disturbances: Evaluation involves analysis and clinical decision-making, which must be performed by the nurse, not the UAP.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

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

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

A client with a history of alcohol addiction says, "My body feels fine when I abstain from alcohol consumption, but I miss my late night glasses of wine." Which concept should the nurse discuss with the client?

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?