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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

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ask the client about gastrointestinal pain: PPIs reduce gastric acid secretion, which relieves symptoms such as heartburn, epigastric pain, and discomfort related to peptic ulcer disease or GERD. Assessing the client’s report of pain evaluates whether the medication is effective.

B. Auscultate for bowel sounds in all quadrants: Bowel sounds indicate gastrointestinal motility rather than acid suppression. PPIs do not directly affect peristalsis, so auscultation is not a reliable measure of drug effectiveness.

C. Measure the client's fluid intake and output: Fluid balance is important in overall patient care but is not a direct indicator of how well a PPI is working. Intake and output monitoring is more relevant to renal or fluid management.

D. Monitor the client's serum electrolyte levels: Electrolyte monitoring may be necessary with prolonged PPI therapy due to risks such as hypomagnesemia, but it does not provide immediate information on short-term medication effectiveness.

A. Notify the unit manager that an emergency court order is needed to allow surgery. B. Continue to provide life support until a thorough search for a guardian is completed. C. Carry on with surgical preparation of the client without a signed informed consent. D. Ask the client's friend to sign the informed consent since the client is unresponsive.

Correct Answer is C

Explanation

A. Notify the unit manager that an emergency court order is needed to allow surgery: Obtaining a court order can take significant time and is not feasible in a life-threatening emergency. Delaying surgery could result in serious harm or death.

B. Continue to provide life support until a thorough search for a guardian is completed: While life support stabilizes the client, delaying definitive treatment when immediate surgery is required may worsen outcomes. Emergency protocols allow treatment without consent in life-threatening situations.

C. Carry on with surgical preparation of the client without a signed informed consent: In emergencies where the client is unresponsive and immediate surgery is necessary to preserve life, healthcare providers can proceed without consent under the principle of implied consent. This ensures prompt, potentially life-saving intervention.

D. Ask the client's friend to sign the informed consent since the client is unresponsive: A friend does not have legal authority to provide consent unless formally designated as a healthcare proxy. Relying on the friend could delay urgent care and is not legally valid.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Correct Answer is A

Explanation

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Correct Answer is C

Explanation

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

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?

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.

Patient Data Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.