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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.

1400

1200

1800

1600

0800

2000

1500

Answer and Explanation

Correct Answer : B,D,E,F,G

The order is vital signs to be taken every 4 hours

Additional vital signs should be document when the client’s status changes like the diaphoresis seen at 1500 as this could signify a complication.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

B. This response demonstrates empathy and acknowledges the client's frustration without condoning or reacting defensively to their cursing. It validates the client's feelings and opens the door for further communication about their needs and concerns.
A. This response acknowledges the client's struggle and offers a solution for future assistance with dressing. However, it may not effectively address the client's current frustration and emotional distress.
C. This response addresses inappropriate behavior but does not directly address the client's frustration or provide support for their current situation.
D. This response focuses on the technical aspect of dressing and does not address the client's emotional distress or frustration. It may come across as dismissive of the client's feelings.

A. Use standard precautions and wear a mask. B. Send wound drainage for culture and sensitivity. C. Institute contact precautions for staff and visitors. D. Explain the purpose of a low bacteria diet. E. Monitor the client's white blood cell count.

Correct Answer is ["B","C","E"]

Explanation

B. Sending wound drainage for culture and sensitivity helps identify the specific bacteria causing the infection and determine the most appropriate antibiotic therapy.
C. Instituting contact precautions for staff and visitors is essential to prevent the spread of MRSA to other clients and healthcare workers.
E. Monitoring the client's white blood cell count can provide information about the body's response to infection and the effectiveness of treatment.
A. While using standard precautions, including wearing a mask, is a general practice, it is not specifically required for MRSA unless there is a risk of droplet transmission, which is not typical for MRSA infections.
D. Explaining the purpose of a low bacteria diet (Option D) is not a standard intervention for MRSA infections.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

Patient Data Exhibits Drag from the Word Choices to complete the sentence. The nurse determines the client is near death as evidenced by

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

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?

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

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.