Patient Data

Exhibits

The nurse is implementing the plan of care to increase mobility

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.

Answer and Explanation

The Correct Answer is []

Type of Exercises

Isometric exercises

Actions to Take

Support the extremity during exercise routine

Providing support helps to ensure that the extremity is not subjected to undue stress or movement that could disrupt healing or cause pain.

Teach family how to participate in exercise program

Involving family members can ensure that the client receives consistent support and assistance with exercises, which is particularly important for adherence and progress.

Parameters to Monitor

Pain level

Monitoring pain levels is crucial to ensure that the exercises are not causing undue discomfort or exacerbating the client's condition.

Ability to perform activities of daily living

Assessing the client’s ability to perform ADLs helps gauge functional progress and overall recovery, indicating how well the exercises and rehabilitation are supporting daily functioning.

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Correct Answer is []

Explanation

Condition:

Osmotic diarrhea

osmotic diarrhea. This type of diarrhea is often caused by an imbalance in the osmolality of the intestinal contents, which can be due to certain medications or dietary factors. In this case, the client's recent antibiotic therapy and diet might contribute to this condition.

Actions to Take:

Collect stool for culture – This can help determine if there is an infectious or bacterial component contributing to the diarrhea.

Start a high fiber diet – Increasing dietary fiber can help in managing diarrhea by increasing stool bulk and improving consistency.

Parameters to Monitor:

Serum potassium – Osmotic diarrhea can lead to electrolyte imbalances, and monitoring potassium levels helps to detect potential deficiencies.

Serum ketones – This can help to evaluate if the client is in a state of ketosis due to potential malabsorption or significant diarrhea.

A. Elevate the head of bed 45 degrees. B. Review the advanced directive document. C. Irrigate the nasogastric tube with water. D. Perform oropharyngeal suctioning.

Correct Answer is D

Explanation

A. While elevating the head of the bed is generally recommended for clients with NG tubes to prevent aspiration, it is not the immediate priority when the client is actively vomiting and choking. This action might be taken after the airway is cleared.
B. Reviewing the advanced directive is important for end-of-life care planning, but it does not address the immediate life-threatening situation of the client choking.
C. Irrigating the NG tube is not appropriate in this situation as the client is actively vomiting and choking, indicating a potential airway obstruction.
D. The client is experiencing a life-threatening situation requiring immediate intervention to clear the airway. Oropharyngeal suctioning will remove any vomitus or secretions obstructing the airway and allow the client to breathe effectively.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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?

Correct Answer is D

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

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?

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The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

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