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.

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Correct Answer is D

Explanation

A. "You should not worry about the growth tables. They are only averages for children.": Growth charts are standardized tools used to compare a child’s development with expected norms. Dismissing the concern overlooks an important clinical sign and fails to address the parent’s valid question.

B. "Haven't you been feeding according to recommended daily allowances for children?": This response places blame on the parent and does not acknowledge the child’s medical condition. It may also create unnecessary guilt rather than offering supportive education.

C. "Does your child seem mentally slower than his peers also?": Asking about developmental delay in this way is inappropriate and insensitive. It shifts the focus to cognitive ability rather than addressing the physical growth concern directly tied to the child’s condition.

D. "The smaller size is probably due to the heart disease.": Children with congenital heart defects often experience poor growth because of increased metabolic demands and reduced energy available for growth. This response gives the parent a clear, accurate explanation while validating the concern.

Correct Answer is {"dropdown-group-1":"A"}

Explanation

A. Opioid analgesics: The client reports severe, sharp, stabbing pain with breathing and movement due to multiple rib fractures. Opioids are effective for managing moderate to severe pain, allowing the client to breathe deeply, cough effectively, and reduce the risk of complications such as atelectasis or pneumonia.

B. Antibiotics: There is no evidence of infection in this client’s presentation. Antibiotics are not indicated for pain management related to rib fractures or atelectasis without infection.

C. Antacids: Antacids are used to treat gastrointestinal upset or acid-related conditions. They do not address musculoskeletal pain or improve respiratory function in rib fractures.

D. Bronchodilators: Bronchodilators relieve airway constriction in conditions like asthma or COPD. This client’s shallow breathing is due to pain, not bronchospasm, so bronchodilators are not appropriate.

E. Antihypertensives: While the client has slightly elevated blood pressure, antihypertensives do not relieve pain or improve respiratory effort, making them irrelevant for the acute management of rib fracture–related symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

Correct Answer is {"dropdown-group-1":"A"}

Explanation

A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

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.

The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks, "How will I know that my husband's death is imminent? Our two adult children want to be here when their father dies." Which is the best response by the nurse?

The nurse is assessing the body alignment of an immobilized client. Which is the best client position for the nurse to obtain an accurate assessment?

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?