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Patient Data

Exhibits

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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

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

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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 D

Explanation

A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days: While educating the client about notifying contacts is important, it does not prevent immediate transmission within the healthcare setting. It is a secondary measure.

B. Update the client and family regarding the COVID-19 vaccines that are available: Providing vaccine information is useful for long-term prevention but does not address the urgent need to reduce the risk of transmission from a potentially contagious client.

C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: Assigning the client to a designated area is important for infection control, but the immediate priority is preventing exposure to others while awaiting placement.

D. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE: Immediate isolation is the most critical action to prevent the spread of COVID-19. This protects other clients, visitors, and staff while testing and further management are arranged.

A. Ask the client about gastrointestinal pain. B. Auscultate for bowel sounds in all quadrants. C. Measure the client's fluid intake and output. D. Monitor the client's serum electrolyte levels.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

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

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?

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

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 plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

A 4-month-old with hydrocephalus is admitted to the hospital for shunt revision. When assessing for increased intracranial pressure, the nurse should observe the child for which finding(s)? Select all that apply.