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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Administering antipyretic medication as needed

Educating client and family on the importance of fluid restrictions

Collaborating with dietician to prepare low protein diet

Monitoring fluid status

Investigating acid/base complication

Assessing for worsening respiratory status

Performing diagnostic testing to determine cause of fever

Reassessing vital signs

Identifying cardiac arrhythmias

Answer and Explanation

Correct Answer : D,F,I

A.   Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B.   Client and family education on fluid management is important but can be addressed after assessing hydration status.
C.   Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D.   Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E.   The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F.   The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G.   Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H.   Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I.   The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

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Correct Answer is D

Explanation

A. While important, immediate assignment to a COVID-19 area is secondary to infection control precautions.
B. Proper handling of the specimen is essential but secondary to immediate safety measures.
C. Starting antiviral drugs would only occur after a positive test result.

D. Maintaining a 6 feet distance and wearing appropriate PPE is the most important action to prevent transmission of the virus.

A. Bends from the waist to pick trash off the floor. B. Leans forward to pull a pan from a high shelf. C. Locks knees while preparing food on the counter. D. Widens stance while working near the sink. E. Brings a heavy can close to body before lifting.

Correct Answer is ["D","E"]

Explanation

A. Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B. Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C. Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

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Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Correct Answer is ["D","E"]

Explanation

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

The nurse is managing the care of a client with Cushing's syndrome. What intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

A client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client?

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's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?