The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action?

Advise the UAP to stop providing care so the nurse can assess the client's condition.

Determine why the UAP did not notify the nurse of the change in the client's condition.

Ask the UAP to position the client so the oral medications can be administered.

Explain to the UAP that changes in a client's condition should be reported immediately.

Answer and Explanation

The Correct Answer is A

A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.

B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.

C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.

D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Plumb line test indicates fetal position curvature: This assessment is used to evaluate spinal alignment and posture, not hip integrity. It does not explain asymmetrical buttocks in a newborn.

B. Ortolani maneuver causing a click at the hip joint: A positive Ortolani sign (a “click” or “clunk”) indicates hip dysplasia or subluxation. This finding is significant and should be reported to the healthcare provider for further evaluation and management.

C. Babinski test that reveals fanning out of toes: The Babinski reflex is normal in newborns and does not indicate musculoskeletal abnormality. It is unrelated to asymmetrical buttocks.

D. Moro test precipitating a startle response: The Moro reflex is a normal newborn response and does not indicate hip instability or asymmetry in the buttocks.

A. Explain the purpose of a low bacteria diet. B. Use standard precautions and wear a mask. C. Monitor the client's white blood cell count (WBC). D. Institute contact precautions for staff and visitors. E. Send wound drainage for culture and sensitivity.

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

Explanation

A. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is indicated for immunocompromised clients, not for MRSA wound infections. It does not reduce transmission or address wound healing.

B. Use standard precautions and wear a mask: Standard precautions are necessary, but a mask is not required for MRSA unless there is risk of aerosolization (e.g., respiratory infection). The key precaution is contact isolation, not routine mask use.

C. Monitor the client’s white blood cell count (WBC): Tracking WBC trends helps identify worsening infection or systemic involvement such as sepsis. This is an important part of managing MRSA.

D. Institute contact precautions for staff and visitors: MRSA is transmitted by direct contact with infected drainage or contaminated surfaces, so gown and glove use with contact precautions are essential.

E. Send wound drainage for culture and sensitivity: Culturing identifies the causative organism and determines antibiotic sensitivity, which guides effective treatment planning.

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Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

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

Explanation

Which finding should the nurse recognize as a potential complication in a client with hypertension?

The nurse is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

Patient Data Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.