Patient Data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Anthrax

The client's flu-like symptoms followed by shortness of breath, cough, and chest pain align with potential inhalation anthrax. Furthermore, working in a government building and opening a suspicious package containing white powder suggests potential exposure to anthrax spores.
Actions to Take:

Place the client in isolation - Isolating the client helps prevent potential transmission of anthrax to others.
Apply oxygen via nasal cannula: The client's low oxygen saturation (88%) necessitates oxygen therapy to improve oxygen delivery to tissues.

Parameters to Monitor:

Arterial blood gases - Monitoring arterial blood gases helps assess the client's respiratory status and oxygenation levels, which may be compromised in anthrax-related respiratory distress.
Breath sounds - Monitoring breath sounds helps assess the effectiveness of respiratory interventions and detect any changes indicative of worsening respiratory status.

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Correct Answer is B

Explanation

A. Sluggish blood return suggests a need for assessment but is not immediately critical.

B. A red streak tracking the vein indicates phlebitis or infection, requiring immediate intervention to prevent complications such as thrombophlebitis or sepsis.
C. Circumferential skin irritation is concerning but not as urgent as a sign of infection.
D. A cool sensation might indicate infiltration but is less critical compared to signs of infection or phlebitis.

A. Bring a sterile chest drainage unit from central supply to the unit. B. Call the pharmacy to obtain a client's next antibiotic dose. C. Observe a client's gait to determine the need for assistance. D. Evaluate a client's urinary catheter for proper drainage.

Correct Answer is A

Explanation

A. Bringing a sterile chest drainage unit from central supply is a task that does not require clinical judgment and is suitable for a UAP.
B. Calling the pharmacy involves understanding and communication about medications, which should be handled by licensed staff.
C. Observing a client's gait to determine the need for assistance involves assessment and clinical judgment, which is beyond the UAP's scope.

D. Evaluating a client's urinary catheter for proper drainage requires assessment skills that are within the scope of licensed nurses.

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Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Correct Answer is B

Explanation

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

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Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Patient Data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.