Temperature: 96.9 F (36.1 C) measured via internal probe via urinary catheter.

Heart rate: 128 beats/minute, sinus tachycardia (ST). Respirations: 14 breaths/minute.

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg. Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2). IV fluid bolus given as prescribed.

The client’s surgical dressing is clean and dry.

Ecchymosis is noted on the abdomen around the dressing.

The client has a peripheral intravenous (PIV) line in the right forearm and one in the left hand.

The client also has a right subclavian central venous catheter infusing propofol and intravenous fluids.

Heart sounds are regular.

The skin is pink.

Capillary refill is 6 seconds.

Radial pulses are equal bilaterally.

Lung sounds are clear and equal bilaterally.

The client has an indwelling urinary catheter in place.

No urine is noted.

The client has no visitors at this time.

The social worker is attempting to contact family members.

The client opens her eyes to verbal stimuli and follows verbal commands.

Based on these observations, what is the most appropriate nursing action?

Increase the rate of IV fluids.

Administer pain medication.

Monitor the client’s urine output.

Consult with the healthcare provider.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Increasing the rate of IV fluids is the most appropriate nursing action based on the client's clinical presentation. The client has signs of hypovolemia, including tachycardia, low blood pressure with a narrow pulse pressure, and delayed capillary refill. An IV fluid bolus is often prescribed to improve intravascular volume and perfusion. Monitoring the client's response to increased IV fluids is essential to ensure effective treatment.

Choice B rationale

Administering pain medication is important for managing the client's comfort, but it is not the priority action in this situation. The client's vital signs indicate hypovolemia, which needs to be addressed promptly. Pain management can be considered after stabilizing the client's hemodynamic status.

Choice C rationale

Monitoring the client's urine output is important for assessing renal perfusion and fluid balance. However, with the current clinical presentation indicating hypovolemia, the priority action is to increase the rate of IV fluids to improve intravascular volume and perfusion.

Choice D rationale

Consulting with the healthcare provider is important for collaborative care and decision-making. However, the priority action in this situation is to address the client's signs of hypovolemia by increasing the rate of IV fluids. Immediate intervention is needed to stabilize the client's hemodynamic status before further consultations.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale

An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.

Choice B rationale

An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.

Choice C rationale

An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.

Choice D rationale

An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.

A. Don an N95 respirator mask, face shield, gown, gloves, and shoe coverings prior to returning to the room. B. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. C. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. D. Notify the charge nurse that the client will need assignment to the COVID-19 specified area of the facility.

Correct Answer is A

Explanation

Choice A rationale

Donning appropriate personal protective equipment (PPE), including an N95 respirator mask, face shield, gown, gloves, and shoe coverings, is crucial to protect the nurse from potential exposure to the virus during close contact with a symptomatic client.

Choice B rationale

Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.

Choice C rationale

Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.

Choice D rationale

Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is D

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?

Correct Answer is A

Explanation

A nurse is caring for a 59-year-old male client in the intermediate care unit. Exhibits Which of the following findings requires the nurse's immediate attention?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.