Patient Data

Exhibits
The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record.
Nursing Action: Indicated/ Contraindicated

IV 0.9% normal saline continuous infusion at 100

Daily weights

Calculation of intake and output

IV potassium sparing diuretic

Continuous pulse oximetry monitoring

Electrocardiogram monitoring

Answer and Explanation

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

A.   Given the client's chronic kidney disease and the risk of fluid overload, a high rate of normal saline infusion may not be appropriate without careful assessment and specific indication from the healthcare provider.
B.   Monitoring daily weight is essential in managing fluid balance and assessing for potential fluid overload, especially in a child with chronic kidney disease.

C.   Accurate measurement of intake and output is crucial in managing fluid balance and monitoring kidney function, particularly in a patient with a history of acute kidney injury and chronic kidney disease.
D.   The client already has an elevated potassium level, and administering a potassium-sparing diuretic could worsen hyperkalemia, leading to dangerous cardiac complications.
E.   Continuous monitoring of oxygen saturation is important due to the presence of bibasilar infiltrates on the chest X-ray, which could indicate a potential respiratory issue.
F.   ECG monitoring is indicated due to the elevated potassium level (5.3 mEq/L), which can cause cardiac arrhythmias. The irregular heart rate further supports the need for ECG monitoring.

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. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.
B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.
C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.
D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.

A. Find outlets for more social interaction. B. Think about reasons the episodes occur. C. Practice using muscle relaxation techniques. D. Center attention on positive upbeat music.

Correct Answer is C

Explanation

A. Social interaction can help, but it is not the most effective immediate strategy for managing anxiety.
B. Reflecting on the reasons for anxiety is useful for long-term management but not for immediate relief.
C. Muscle relaxation techniques are an effective and immediate method for reducing anxiety symptoms.
D. Listening to music can help but is less effective than targeted relaxation techniques.

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Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

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?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

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

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?

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. What food choice(s) included on the client's list should the nurse encourage? Select all that apply.

Patient Data

Exhibits
The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record.
Nursing Action: Indicated/ Contraindicated