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The client had a large, loose stool.

Vital signs: Temperature 98.7°F (37°C) orally. Heart rate 73 beats/minute.

Blood pressure 144/82 mm Hg. The client had a large, loose stool. The client had a large, loose stool.

Place the client on contact precautions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take, and two parameters to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

The correct answer is Potential Condition:

A. Secretory diarrhea.

Actions to Take:

A. Collect stool for culture.

D. Make the client NPO.

Parameters to Monitor:

A. Heart rate.

B. Serum potassium.

Potential Condition A rationale:

Secretory diarrhea is characterized by large volumes of watery stool and can be caused by infections, toxins, or certain medications. It is important to identify the underlying cause to provide appropriate treatment. Potential Condition B rationale:

Steatorrhea is characterized by fatty stools and is typically associated with malabsorption syndromes. The client’s symptoms do not suggest this condition. Potential Condition C rationale:

Motility diarrhea is caused by rapid transit of stool through the intestines, often due to conditions like irritable bowel syndrome. The client’s symptoms are more consistent with secretory diarrhea. Potential Condition D rationale:

Osmotic diarrhea occurs when non-absorbable substances draw water into the intestines. The client’s symptoms are more indicative of secretory diarrhea. Action A rationale:

Collecting stool for culture helps identify any infectious agents that may be causing the diarrhea, allowing for targeted treatment. Action B rationale:

Starting a high-fiber diet is not appropriate for a client with acute diarrhea, as it may exacerbate symptoms. Action C rationale:

Administering an oral steroid is not indicated for the treatment of secretory diarrhea and may worsen the condition. Action D rationale:

Making the client NPO (nothing by mouth) helps to rest the gastrointestinal tract and reduce the severity of diarrhea. Parameter A rationale:

Monitoring heart rate is important as dehydration from diarrhea can lead to tachycardia. Parameter B rationale:

Monitoring serum potassium is crucial as diarrhea can lead to significant electrolyte imbalances, including hypokalemia. Parameter C rationale:

Monitoring respiratory rate is not directly related to the management of diarrhea. Parameter D rationale:

Monitoring urine sodium is not directly related to the management of diarrhea.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale
Encouraging increased fluid intake and measuring urinary output every 8 hours is not directly related to managing chronic pain. This intervention is more relevant for clients with conditions affecting fluid balance or renal function.
Choice B rationale
Providing comfort measures such as topical warm application and tactile massage can help alleviate chronic pain by promoting relaxation and improving blood circulation. These non- pharmacological interventions can be effective in managing pain and enhancing the client’s comfort.
Choice C rationale
Determining the client’s objective measure of pain using a numerical pain scale is essential for assessing the severity of pain and evaluating the effectiveness of pain management interventions. Accurate pain assessment is crucial for developing an appropriate plan of care.
Choice D rationale
Assisting the client to ambulate as much as possible during waking hours may not be feasible for clients with severe chronic pain. While physical activity is important, it should be balanced with the client’s pain levels and overall condition.
Choice E rationale
Implementing a 24-hour schedule of routine administration of prescribed analgesics ensures consistent pain relief and prevents breakthrough pain. Regular administration of analgesics is a key component of effective pain management for clients with chronic pain.

A. Withdraw the medication into a syringe and label with the client’s name. B. Ask another nurse to witness the medication being discarded. C. Place the vial with the remainder of the medication into a locked drawer. D. Throw the vial into the trash in the presence of another nurse.

Correct Answer is B

Explanation

Choice A rationale
Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and could lead to errors or contamination.
Choice B rationale
Asking another nurse to witness the medication being discarded ensures proper documentation, accountability, and compliance with regulations.
Choice C rationale
Placing the vial with the remainder of the medication into a locked drawer does not address the need for proper documentation and labeling of the remaining medication.
Choice D rationale
Throwing the vial into the trash in the presence of another nurse is not appropriate as it does not ensure proper documentation, accountability, or safe storage of the remaining medication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is B

Explanation

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A client voided clear, yellow urine.

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?

Which assessment should the nurse document when charting by exception?

What times should the nurse measure vital signs? Select all that apply.

A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

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?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?