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 C

Explanation

C. A tort is a wrongful act or an infringement of a right that leads to civil legal liability. Restraint use should be based on a healthcare provider's order and should follow institutional policies and procedures. Administering restraints without proper authorization can result in legal liability, as it may constitute false imprisonment or battery.
A. In an emergency situation where a client is agitated and poses a risk to themselves or others, it may be necessary to enlist security personnel to help ensure the safety of everyone involved.
B. Administering medication behind a closed curtain is a common practice to provide privacy and confidentiality to the client.
D. Intentionally misleading a client about the nature of the medication being administered constitutes a form of deceit or fraud. However, this is not considered a tort.

A. if the popsicles are completely frozen. B. How many popsicles are available. C. The color and flavor of gelatin used. D. Whether they contain pulp or fruit.

Correct Answer is A

Explanation

A. If the popsicles are completely frozen. This is the most crucial information in this scenario. Clear liquids are recommended for a child who has been vomiting, and if the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child's condition.
B. Knowing the quantity of popsicles available can help the nurse assess the child's potential intake of fluids and ensure that an adequate supply is on hand if needed.
C. The color and flavor of gelatin used is important because certain colors and flavors of gelatin may contain additives or artificial ingredients that could potentially worsen the child's condition or cause discomfort.
D. While it’s important that clear liquids do not contain pulp or solid materials, in this scenario, the immediate concern is the state of the popsicles (frozen or not) rather than their composition.

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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

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Correct Answer is C

Explanation

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is A

Explanation

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

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After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

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.

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?

Patient Data Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by