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Find patient data below.

Exhibits here

What actions should the nurse plan for the rest of the shift? Select all that apply.

Monitor the oxygen saturation

Discuss aggressive respiratory treatment options

Obtain a sputum culture

Allow the client to take a position of comfort

Discuss with the client potential asthma triggers

Consider positive pressure ventilation

Wean the supplemental oxygen

Prepare for deep tracheal suctioning

Answer and Explanation

Correct Answer : A,D,E

A)   Correct- Continuous monitoring of oxygen saturation ensures the client's oxygen levels remain within an acceptable range.
B)   Incorrect - Discussing aggressive respiratory treatment options is not warranted based on the provided information. The current treatment plan includes appropriate interventions.
C)   Incorrect - Obtaining a sputum culture is important for identifying infections, but it's not an immediate action in the context of the client's current symptoms.
D)   Correct- Promoting comfort can help reduce anxiety and potentially improve breathing.
E)   Correct- Educating the client about potential triggers supports better self-management.
F)   Incorrect - Considering positive pressure ventilation is not indicated at this stage. The client's symptoms are being managed with other interventions.
G)   Incorrect - Weaning supplemental oxygen is not mentioned in the patient data or nurses' notes as something that's currently necessary.
H)   Incorrect - Preparing for deep tracheal suctioning is not warranted based on the patient data and the current treatment plan.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.

A. An abduction pillow is placed between the client's legs when positioned. B. The client is told to keep both legs straight and together while turning. C. A turning sheet is used under the client for turning and repositioning. D. The UAPs keep their backs straight and knees bent when moving the client.

Correct Answer is B

Explanation

This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the aﬀected leg slightly abducted and supported with pillows or an abduction device.

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Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

Correct Answer is C

Explanation

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

Correct Answer is B

Explanation

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.

A client is receiving mesalamine 800 mg by mouth three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

Find patient data below.

Exhibits here

What actions should the nurse plan for the rest of the shift? Select all that apply.