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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suﬀered a myocardial infarction (MI) or heart atack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.

The other options are not correct because:

The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood ﬂow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood ﬂow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.

A. “Come into the recreation area. We have your favorite card game and I will play it with you." B. "Why do you want to stay in your room today?” C. "I know you are sad about not seeing your family as often, but they are visiting as much as they can.” D. d “May I sit with you for a while?"

Correct Answer is D

Explanation

d. “May I sit with you for a while?"

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and oﬀers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.
This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.
This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

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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

Correct Answer is A

Explanation

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is D

Explanation

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?

An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

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.

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

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

The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective?

After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

Find patient data below.

Exhibits here

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