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

Place all client belongings out of reach

Instruct the client to call before getting up

Initiate use of the bed alarm

Complete a swallow study before giving anything by mouth

Place the client in a room near the elevator

Provide a call button kept within reach

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

A.   placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B.   Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C.   Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D.   Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E.   Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F.   Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B.Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C.Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D.Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

A. Propose that the nurse use the antecubital site for IV access. B. Send an unlicensed assistive personnel to gather equipment. C. Direct the nurse to remove the needle before the procedure. D. Suggest starting a secondary infusion at the IV tubing

Correct Answer is C

Explanation

A. Suggesting the antecubital site does not address the immediate issue of using an inappropriate needle size.
B. Sending a UAP to gather equipment is not an immediate action needed to correct the mistake.
C. Using an 18-gauge needle to irrigate an IV catheter is inappropriate and could damage the catheter. The charge nurse should instruct the new nurse to remove the needle and use a syringe without a needle to perform the irrigation safely.
D. Starting a secondary infusion is unrelated to the irrigation process and does not correct the inappropriate needle use.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Correct Answer is B

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

Correct Answer is C

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.

A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?

The nurse implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective?

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Exhibits Drag from the word choices to complete the sentence The client demonstrates effective epidural anesthesia by and ,

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