The nurse continues to assist in the care of the client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first ensure administration of the client's e to the client's
dropdown
due to the client’s
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale:

• Antibiotic: Administering an antibiotic addresses the underlying infection, which is likely causing the fever, low blood pressure, and altered mental status. Prompt antibiotic treatment reduces the risk of progression to septic shock. Early intervention improves patient outcomes in suspected sepsis.

• Antipyretic: An antipyretic helps reduce fever but does not treat the underlying infection. Lowering the temperature alone would not address the systemic inflammatory response seen in sepsis. This option does not prevent clinical deterioration.

• Anti-anxiety medication: An anti-anxiety medication may temporarily calm the patient but can worsen confusion and mask signs of deterioration. It does not treat the infection or improve hemodynamic status. This is inappropriate in suspected sepsis.

• Suspected surgical site infection and sepsis: The inflamed, draining surgical wound, fever, hypotension, and high WBC strongly indicate a developing infection. Mental status changes are also typical in sepsis. This makes infection the most urgent concern requiring antibiotic therapy.

• Elevated temperature and heart rate: While these signs are concerning, they are common with many conditions and not specific to sepsis. They are part of the clinical picture but not the driving reason for immediate antibiotic treatment.

• History of Parkinson’s disease and confusion: The confusion may partly relate to Parkinson’s or sensory impairment, but acute mental status changes with fever and hypotension suggest sepsis. Parkinson’s is chronic and not the immediate priority.

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Correct Answer is B

Explanation

Rationale:

A. "I should be able to follow my normal routine after the staples are removed from my incision.” Normal activities should be resumed gradually; simply removing staples does not mean the incision and abdominal muscles have fully healed.

B. "I will ask my partner to perform household chores until my incision is healed." Delegating strenuous tasks supports proper healing and prevents strain on the incision site, reflecting appropriate understanding of postpartum activity restrictions.

C. "I will wait 4 to 6 weeks to perform kegel exercises." Kegel exercises can usually begin soon after delivery to strengthen pelvic floor muscles and are not delayed for several weeks unless specifically advised.

D. "I will maintain modified bed rest for the first 48 to 72 hours at home." While initial rest is important, prolonged bed rest can increase the risk of complications like blood clots. Gradual ambulation is encouraged to promote circulation and recovery.

A. Administer haloperidol via the intramuscular route. B. Collect data regarding the client's feelings. C. Obtain assistance to apply wrist restraints. D. Move the client into the seclusion room.

Correct Answer is B

Explanation

Rationale:

A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.

B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.

C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.

D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.

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The nurse continues to assist in the care of the client. Exhibits Complete the following sentence by using the lists of options. The nurse should first ensure administration of the client's e to the client's dropdown due to the client’s dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching about postpartum activity restrictions to a client who had a cesarean birth 2 days ago. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?

A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?

A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?

A nurse is caring for a client who has rheumatoid arthritis and is having difficulty with ADLs, such as cooking and eating. The nurse should ensure that the client has a referral to which of the following members of the interprofessional team?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in sodium?

A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

The nurse is assisting in the administration of IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings indicate an allergic reaction to the medication?

The nurse continues to assist in the care of the client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first ensure administration of the client's e to the client's
dropdown
due to the client’s
dropdown
.