The client is a 49-year-old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history

The client has an oxygen saturation of 96% on 8 L simple face mask. The nurse assesses the client, and he is feeling less restless and anxious. His heart rate is now 79 bpm, blood pressure 119/73 mmHg, and respiratory rate 24.

What are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge?

The client will report pain less than 3/10

The client will have quit smoking

The client will remain free of skin breakdown

The client will maintain oxygen saturation of 96% without supplemental oxygen

The client will be afebrile for 24 hours

Answer and Explanation

Correct Answer : B,D,E

A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.

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Correct Answer is A

Explanation

A. Checking for a distended bladder is the priority action because a distended bladder can contribute to uterine atony and excessive bleeding postpartum.
B. Reviewing the hemoglobin to determine hemorrhage may be necessary, but assessing for a distended bladder takes precedence as it can directly affect uterine tone.
C. Massaging the uterus to decrease atony may be appropriate if the uterus is boggy, but in this scenario, the uterus is firm.
D. Increasing intravenous infusion may be necessary if the client is hypovolemic, but assessing for a distended bladder should be done first to address potential causes of uterine atony.

A. An adolescent with multiple contusions due to a fall that occurred 2 days ago. B. A 75-year-old client with renal calculi who requires urine straining. C. A 30-year-old depressed client who admits to suicide ideation. D. A 64-year-old client who had a total hip replacement the previous day.

Correct Answer is C

Explanation

A: An adolescent with multiple contusions due to a fall that occurred 2 days ago can be managed by the PN as the condition is stable and does not require the advanced skills of an RN.
B: A 75-year-old client with renal calculi who requires urine straining can also be assigned to the PN because urine straining is a task within the PN's scope of practice.
C: A 30-year-old depressed client who admits to suicide ideation requires the expertise of an RN due to the need for continuous assessment, potential for crisis intervention, and the complexity of care needed.
D: A 64-year-old client who had a total hip replacement the previous day would typically be stable post-operation and could be managed by the PN, with the RN available for any complications that may arise.

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Body System	Assessment Finding
Cardiovascular	BP 145/89 mmHg Heart Rate 101 bpm Capillary refill 4 seconds
Neurologic	Awake and alert Anxious and Restless
Respiratory	Oxygen saturation 90% Respiratory rate 28bpm Productive cough

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Correct Answer is A

Explanation

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

Correct Answer is C

Explanation

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

The nurse is caring for a group of clients with the help of a practical nurse (PN) Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

To auscultate for a carotid bruit, the nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location.)