Patient Data

Exhibits

Drag one condition and one client finding to complete the sentence(s).

Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of
as evidenced by
.

neurological defects as evidenced by

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

The client presents with facial droop and garbled speech, which are classic symptoms of a stroke. The CT scan ruled out intracranial hemorrhage, aligning with ischemic stroke symptoms. The neurological assessment indicated left-sided facial droop, diminished hand grasp strength, and garbled speech, all of which are consistent with neurological deficits typically seen in a stroke.

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

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. Oxygen saturation 98% on room air B. Urine output 20 mL in the last hour C. Basilar crackles D. Heart rate 72 beats/minute E. Respiratory rate 26 breaths/minute F. Blood pressure 126/76 mm Hg G. Electrocardiogram Tall T wave and widened QRS complex H. Temperature 98.9° F (37.1° C) orally

Correct Answer is ["A","D","E","F","H"]

Explanation

A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.

G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.

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Patient Data Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of as evidenced by. neurological defects as evidenced by

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

Correct Answer is ["A","D","E","F","H"]

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement?

A client receives a prescription for acetaminophen 1,000 mg PO every 8 hours PRN for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

Exhibits Nursing actions: Indicated/contraindicated/non-urgent

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

Patient Data

Exhibits

Drag one condition and one client finding to complete the sentence(s).

Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of
as evidenced by
.

neurological defects as evidenced by