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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.

1500.

1600.

1800.

1000.

1200.

0800.

1400.

2000.

Answer and Explanation

Correct Answer : A,B,C,G,H

Choice A rationale
Measuring vital signs at 1500 is crucial because the client is diaphoretic and flushed, indicating a potential change in condition that needs monitoring.
Choice B rationale
At 1600, blood glucose was obtained, and it is essential to measure vital signs to assess the client’s response to the insulin lispro given at 1800.
Choice C rationale
At 1800, the client ate 75% of his tray, and 4 units of insulin lispro were administered. Monitoring vital signs at this time helps evaluate the client’s metabolic response.
Choice G rationale
At 1400, the client voided clear, yellow urine. Measuring vital signs at this time provides a baseline for comparison with subsequent readings.
Choice H rationale
Measuring vital signs at 2000 ensures continuous monitoring and helps detect any late changes in the client’s condition.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

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Correct Answer is B

Explanation

Choice A rationale
Giving the client a hug may not be appropriate in a professional setting and could be perceived as crossing personal boundaries.
Choice B rationale
While touching the client’s forearm, asking “Would you like to talk about it?” is a compassionate and supportive response. It shows empathy and provides the client with an opportunity to express their feelings.
Choice C rationale
Apologizing for disturbing the client and offering to wait until later may not address the client’s immediate emotional needs.
Choice D rationale
Stating that it is a bad time and offering to come back later may not provide the client with the support they need in the moment.

A. Remove dentures or other oral appliance. B. Elevate the head of the bed to a 45-degree angle. C. Apply the client’s positive airway pressure device. D. Put and lock the side rails in place.

Correct Answer is C

Explanation

Choice A rationale
Removing dentures or other oral appliances is not the most critical intervention for a client with severe obstructive sleep apnea (OSA) who has received an opioid analgesic. The priority is to ensure airway patency.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.

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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

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is C

Explanation

A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, “Streptomycin 1 gram/25.”. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Which assessment should the nurse document when charting by exception?

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 with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

A nurse is reviewing error prevention techniques that would have helped to avoid a medication error. Which technique is most effective?

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?

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.