Patient Data

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.
Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Notify the social worker the client is awake.

Explain all procedures

Increase the propofol infusion

Consider extubating the client

Answer and Explanation

Correct Answer : B,F,G,H

A. Notify the social worker the client is awake: The social worker is already attempting to contact family. Awakening does not require immediate notification; the priority is client care and stabilization.

B. Explain all procedures: As the client becomes more alert, clear explanations reduce anxiety, promote cooperation, and support orientation, especially in the ICU environment.

C. Increase the propofol infusion: Increasing sedation without clinical indication may mask neurological changes and hinder assessment. Sedative adjustments should be based on prescribed parameters and provider orders.

D. Consider extubating the client: Extubation is only considered when specific respiratory and hemodynamic criteria are met. Waking up does not automatically mean the client is ready to be extubated.

E. Have the client sign consent forms for procedures already performed: Consent must be obtained prior to procedures. Once completed, retroactive consent is not valid or ethical.

F. Assess the client’s pain: Pain assessment is essential in postoperative and trauma patients, particularly once the client is able to communicate.

G. Determine the client’s decision-making ability: As the client becomes more awake, assessing cognitive status and ability to participate in care decisions is appropriate and supports autonomy.

H. Decrease the noise and light stimuli in the room as much as possible: Minimizing environmental stimuli helps reduce delirium risk, improves comfort, and promotes healing in critically ill patients.

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Correct Answer is A

Explanation

A. Maintain the client on bedrest: The client’s symptoms are consistent with deep vein thrombosis (DVT). Bedrest with limited movement prevents dislodgment of the clot, which could otherwise travel to the lungs and cause a pulmonary embolism. This is the safest initial intervention while anticoagulation is being started.

B. Administer the client's routine daily aspirin: Aspirin has antiplatelet effects but is not the treatment of choice for acute DVT. Starting aspirin with heparin therapy is not recommended, as it increases the risk of bleeding without additional therapeutic benefit.

C. Encourage a diet high in iron and ascorbic acid: While iron and vitamin C support red blood cell production, this dietary intervention does not address the acute management of a thrombus. It may be useful in anemia prevention but is not a priority here.

D. Encourage the client to dangle the legs frequently: Dangling the legs promotes venous stasis and may worsen the clot or increase the risk of embolization. Clients with DVT should avoid activities that increase venous pooling until cleared by the healthcare provider.

A. Increase your water and fiber intake while taking opioids. B. Expect the morphine to take 1 to 2 hours for full effect. C. Request pain medication only if pain is severe. D. Use incentive spirometer when the pain medication takes effect. E. Ask for assistance when getting out of bed after taking morphine.

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

Explanation

Rationale for correct choices:

• Increase your water and fiber intake while taking opioids: Opioids frequently cause constipation by slowing gastrointestinal motility. Encouraging adequate hydration and fiber intake helps prevent constipation and maintain bowel regularity, which is an essential part of opioid education.

• Expect the morphine to take 1 to 2 hours for full effect: IV morphine typically takes effect within 5 to 10 minutes, with peak analgesic effect in about 20 minutes. Telling the client it takes 1 to 2 hours may cause confusion and unnecessary delay in using other comfort measures.

• Request pain medication only if pain is severe: Waiting until pain is severe can result in poor pain control and decreased participation in respiratory exercises. Encouraging timely administration before pain becomes severe promotes better analgesia and facilitates lung expansion.

• Use incentive spirometer when the pain medication takes effect: Pain can limit the client’s ability to perform deep breathing exercises. Using the incentive spirometer when analgesia is effective promotes lung expansion, reduces atelectasis risk, and improves oxygenation in clients with rib fractures.

• Ask for assistance when getting out of bed after taking morphine: Morphine can cause dizziness, orthostatic hypotension, or sedation, increasing fall risk. Asking for assistance ensures client safety during ambulation or position changes, especially in older adults with recent trauma.

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Patient Data Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Patient Data Exhibits The nurse is providing education about opioid pain medication. For each education point, click to indicate whether it is appropriate or not appropriate to provide to the client. Each row must have one response option selected.

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

Explanation

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?

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Patient Data

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.
Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.