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 A

Explanation

A. Redness and swelling of the calf are classic signs of deep vein thrombosis (DVT), especially in an older adult who is immobile. DVT is a common complication in hospitalized patients, particularly those who are immobile or have other risk factors such as dehydration.
B. Fat emboli typically present with symptoms such as dyspnea, tachypnea, and petechial rash, rather than localized redness and swelling of the calf.
C. Pulmonary embolism typically presents with symptoms such as chest pain, dyspnea, tachypnea, and hemoptysis, rather than localized redness and swelling of the calf.
D. While infection can cause localized redness and swelling, the presence of dehydration and immobility increases the likelihood of a thrombotic event such as deep vein thrombosis. It is important to consider DVT as a potential cause of these findings and initiate appropriate diagnostic and preventive measures.

A. Urinalysis. B. White blood cell (WBC count. C. Sputum culture and sensitivity. D. Serum potassium. E. Red blood cell (RBC count. F. Blood urea nitrogen (BUN).

Correct Answer is ["B","C"]

Explanation

A. Urinalysis: While urinalysis can provide information about urinary tract infections, it is not directly related to monitoring the effectiveness of antibiotic treatment for a respiratory tract
infection.
B. White blood cell (WBC count: Monitoring WBC count can help assess the body's response to infection. A decrease in WBC count can indicate improvement in the infection.
C. Sputum culture and sensitivity: Monitoring sputum culture and sensitivity helps determine if the antibiotic is targeting the specific pathogen causing the respiratory tract infection and if the chosen antibiotic is effective against it.
D. Serum potassium: Monitoring serum potassium levels is important with certain antibiotics,
but it is not directly related to evaluating the effectiveness of antibiotic treatment for a respiratory tract infection.
E. Red blood cell (RBC count: RBC count is not typically monitored to evaluate the effectiveness of antibiotic treatment for a respiratory tract infection.
F. Blood urea nitrogen (BUN): BUN levels are not directly related to assessing the effectiveness of antibiotic treatment for a respiratory tract infection.

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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 completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

Correct Answer is A

Explanation

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.

Correct Answer is ["B","C"]

Explanation

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

The healthcare provider prescribes heparin 3 units/kg IV push for a client who weighs 175 pounds. The vial is labeled, "100 units/mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth).

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

The nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA. The client's parent is insisting to know the laboratory test results. Which is the best response for the nurse to provide?

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.