Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by

Decreased muscle tone, relaxed jaw muscles, sagging mouth

Congestion/increased pulmonary secretions; noisy respirations (death rattle)

Altered breathing (apnea, labored or irregular breathing, Cheyne- Stokes pattern)

Urine output is clear yellow

Eating soft foods

Answer and Explanation

Correct Answer : A,B,C

As patient goes into cardiorespiratory failure, there is altered breathing with characteristic gasping and death rattle before complete cessation of breathing. This is followed by cessation of the peripheral nervous system with loss of tone.

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Correct Answer is ["A","D"]

Explanation

A. Establishing a regular sleep schedule helps regulate the body's internal clock, making it easier to fall asleep and wake up at the desired times. Consistency in sleep patterns can improve sleep quality and overall sleep hygiene.
D. Avoiding caffeinated beverages late in the day, particularly in the afternoon and evening, helps prevent interference with the natural sleep-wake cycle. Caffeine is a stimulant that can disrupt sleep by delaying the onset of sleep and reducing total sleep time.
B. While medications may be prescribed for sleep disturbances in some cases, they are typically reserved for short-term use and under the guidance of a healthcare provider.
C. Consuming alcohol close to bedtime can disrupt sleep patterns and lead to poorer sleep quality. While warm beverages such as herbal tea or warm milk may promote relaxation, alcohol is not recommended as a sleep aid.
E. While a short nap earlier in the day may be beneficial for some individuals, especially if they are experiencing daytime sleepiness, taking an afternoon nap can disrupt nighttime sleep patterns and worsen insomnia.

A. Ask the client to describe the pain. B. Provide a numeric pain scale. C. Observe body language and movement. D. Identify effective pain relief measures.

Correct Answer is A

Explanation

A. This approach allows the client to express their experience of pain, including its location, intensity, character, and any associated symptoms, providing valuable information for further assessment and management.
B. While a numeric pain scale can be useful for quantifying the intensity of pain, it primarily focuses on pain intensity rather than pain quality.
C. Observing the client's body language and movement can provide valuable clues about the nature of the pain, such as grimacing, guarding, or writhing. However, while this approach can help assess pain behavior, it may not fully capture the quality of the pain experienced by the client.
D. This approach involves identifying interventions that provide relief from pain but does not directly assess the quality of the pain itself.

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Patient Data Exhibits Drag from the Word Choices to complete the sentence. The nurse determines the client is near death as evidenced by

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Naxlex Comprehensive Predictor Exams

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Correct Answer is ["A","D"]

Explanation

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

Correct Answer is A

Explanation

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate. the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Exhibits Complete the diagram by dragging from the choices area to specify which type of exercises the client needs, two actions the nurse should take to facilitate the exercises, and two parameters the nurse should monitor to assess the client's progress.

Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by