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 []

Cerebral edema is the most likely condition the client is experiencing based on the history of submersion, subsequent resuscitation, and the finding of brain edema noted on the head CT scan.

Implementing seizure precautions is essential because cerebral edema can increase the risk of seizures. Discontinuing the 0.9% sodium chloride solution IV infusion is necessary because hyponatremia (low serum sodium) is associated with cerebral edema, and reducing fluid intake can help manage cerebral edema.

Monitoring strict intake and output is crucial to assess the client's fluid balance and ensure that any changes in fluid status are promptly addressed. Monitoring neurologic status is vital for detecting any changes in consciousness, responsiveness, or neurological function, which could indicate worsening cerebral edema or neurological complications.

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Correct Answer is B

Explanation

A. A rapid, irregular heart rate (e.g., atrial fibrillation) is common in mitral valve stenosis due to atrial enlargement but does not necessarily require immediate intervention unless it leads to severe symptoms like syncope or stroke.

B. Blood-tinged sputum could indicate pulmonary edema or pulmonary hypertension, both of which are serious complications of mitral valve stenosis. This finding warrants immediate intervention as it may signify acute heart failure or other critical complications requiring prompt treatment.

D. Swollen feet and ankles are common signs of fluid retention in heart failure, but they do not require immediate intervention compared to the potential complications of atrial fibrillation.

A. Assume care of the client and assign the PN to the care of a different client. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

- Choice A Rationale: Assuming care of the client and assigning the PN to another client would disrupt the workflow and could lead to confusion. It is important for continuity of care that the PN who began the procedure with the client carries it through to completion.
- Choice B Rationale: Arranging for unlicensed assistive personnel to assist may not be appropriate as they may not have the training or skills required to assist with a sigmoidoscopy, which could compromise patient safety and the integrity of the procedure.
- Choice C Rationale: Acknowledging that the PN has positioned the client safely and correctly would be incorrect because a flat prone position is not the recommended position for a sigmoidoscopy, which typically requires the client to be in a left lateral or Sims' position.
- Choice D Rationale: Demonstrating to the PN how to position the client more effectively is the correct action because it ensures that the client is in the proper position for a sigmoidoscopy, which can enhance the effectiveness of the procedure and patient comfort.

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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

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is B

Explanation

The 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?

Correct Answer is D

Explanation

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Exhibits Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

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Exhibits The nurse reviews the client data. What discharge education should the nurse provide? Select all that apply.

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

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.