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The nurse has reviewed the Vital Signs and Nurses' Notes from 5 weeks ago.

Click to highlight the findings the nurse should report to the provider. To deselect a finding, click on the finding again.

Body System

Findings

Gastrointestinal

Client states, "I'm nauseated all the time. I vomit a few times a day, too." Client states, "I've been a little constipated, but it's not too bad." Abdomen without tenderness on palpation. Bowel sounds hypoactive. Oral mucous membranes sticky.

Genitourinary

Also reports they are urinating less and that urine is dark yellow and odorous. Clean-catch urine specimen obtained. Urine noted to be dark yellow and concentrated

Cardiovascular

Heart rate regular. No edema.

Heart rate 92/min

Blood pressure 102/66 mm Hg

Client states, "I'm nauseated all the time

I've been a little constipated, but it's not too bad

Abdomen without tenderness on palpation

Bowel sounds hypoactive.

Oral mucous membranes sticky

Also reports they are urinating less and that urine is dark yellow and odorous

No edema

Blood pressure 102/66 mm Hg

Urine noted to be dark yellow and concentrated

Answer and Explanation

The Correct Answer is ["A","D","E","F","H","I"]

Rationale for correct choices

• Gastrointestinal: Persistent nausea and frequent vomiting in early pregnancy can lead to dehydration, electrolyte imbalance, and malnutrition. Hypoactive bowel sounds and dry mucous membranes further suggest fluid deficit and possible electrolyte disturbances. Reporting these findings allows the provider to assess severity and initiate interventions.

• Genitourinary: Oliguria and dark, concentrated urine indicate potential dehydration, which can exacerbate nausea and vomiting and compromise kidney function. Early reporting is critical to prevent complications such as acute kidney injury.

• Cardiovascular: The relative hypotension as compared to the baseline blood pressuremay reflect compensatory tachycardia due to dehydration or volume depletion. These vital sign changes warrant reporting because they help the provider assess hemodynamic stability and guide fluid management.

Rationale for incorrect findings:

• Constipation and abdominal palpation without tenderness: Mild constipation without abdominal tenderness is common in early pregnancy due to hormonal changes and is not immediately concerning. It can be managed with dietary fiber, hydration, and gentle activity.

• No edema: The absence of edema indicates no overt fluid retention or preeclampsia at this stage. While monitoring continues, this finding does not require urgent reporting.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Ondansetron: Ondansetron is an antiemetic that works by blocking serotonin receptors in the chemoreceptor trigger zone. It does not significantly affect glucose metabolism and is not associated with hyperglycemia.

B. Guaifenesin: Guaifenesin is an expectorant that thins respiratory secretions to aid clearance. It has no known effect on blood glucose levels or carbohydrate metabolism.

C. Amoxicillin: Amoxicillin is a broad-spectrum penicillin antibiotic. While it treats bacterial infections, it does not typically alter glucose metabolism or cause hyperglycemia as an adverse effect.

D. Methylprednisolone: Methylprednisolone is a corticosteroid that increases gluconeogenesis, decreases peripheral glucose uptake, and antagonizes insulin action. These mechanisms can lead to hyperglycemia, making it the likely cause of the observed increase in the child’s blood glucose.

A. Evaluate the client's ability to help with repositioning B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

Correct Answer is A

Explanation

A. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, motor function, and level of cooperation is essential to determine how much assistance is needed and which repositioning techniques are safest. Stroke clients may have hemiplegia or weakness, and understanding their abilities prevents injury to both the client and the nurse.

B. Reposition the client without the use of assistive devices: Using assistive devices such as slide sheets, gait belts, or mechanical lifts is recommended for clients with limited mobility to reduce the risk of musculoskeletal injury. Repositioning without them increases the likelihood of strain or falls.

C. Discuss the client's preferences for determining a repositioning schedule: While client preferences can enhance comfort and adherence, safety and prevention of complications such as pressure injuries take priority. Scheduling should follow clinical guidelines rather than preference alone.

D. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a fall hazard or limit safe access for the nurse during repositioning. Typically, one side rail may be raised as needed, while the other is lowered to allow safe maneuvering.

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Body System	Findings
Gastrointestinal	Client states, "I'm nauseated all the time. I vomit a few times a day, too." Client states, "I've been a little constipated, but it's not too bad." Abdomen without tenderness on palpation. Bowel sounds hypoactive. Oral mucous membranes sticky.
Genitourinary	Also reports they are urinating less and that urine is dark yellow and odorous. Clean-catch urine specimen obtained. Urine noted to be dark yellow and concentrated
Cardiovascular	Heart rate regular. No edema. Heart rate 92/min Blood pressure 102/66 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's blood glucose. The nurse should identify this finding as an adverse effect of which of the following medications?

Correct Answer is D

Explanation

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance. Use all the steps.)

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray?

The nurse continues to care for the client. Which of the following actions should the nurse take? Select all that apply.

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?

A nurse is providing teaching to a client who has a new diagnosis of type I diabetes mellitus about administering NPH insulin and regular insulin together in one injection. Which of the following instructions should the nurse include?

A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications?