Patient Data

Exhibits

Review H and P, nurse's note, flow sheet, and prescriptions.

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.

Answer and Explanation

The Correct Answer is []

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Inserting a urinary catheter is a skill that typically requires a licensed nurse's expertise.

B. Titrating oxygen requires assessment and adjustment based on clinical findings, which is outside the UAP’s scope of practice.

C. Procuring platelet products from the blood bank is a non-clinical task that can be safely assigned to a UAP.

D. Monitoring an IV infusion rate involves clinical judgment and is typically performed by a licensed nurse.

A. Confirm that this is a common symptom of osteoporosis. B. Determine how the client is administering the medication. C. Advise the client to gargle with warm salt water twice daily. D. Report the client's jaw pain to the healthcare provider.

Correct Answer is D

Explanation

A. Jaw pain is not a common symptom of osteoporosis.

B. While it is important to ensure proper administration of the medication, jaw pain is a serious side effect that requires immediate attention.

C. Gargling with warm salt water may alleviate minor oral discomfort but is not appropriate for managing jaw pain related to bisphosphonate use.

D. Jaw pain is a potential sign of osteonecrosis of the jaw, a serious side effect of bisphosphonates, and should be reported to the healthcare provider immediately.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is D

Explanation

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.