The nurse is caring for a client who has had an upper G.I. endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed assistant to take the vital signs. Two hours later, the assistant reports to client who was previously afebrile has now developed a temperature of 101.8°F. What should the nurse do in response to this reported data by the unlicensed assistant?

Promptly assess the client for a potential perforation

Tell the assistant to change thermometers and retake the temperature

Plan to give the client acetaminophen the lower temperature

Ask the assistant to bathe the client with tap water

Answer and Explanation

The Correct Answer is A

A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.

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Correct Answer is ["A","C"]

Explanation

A. Planning for periods of rest during activities and monitoring the client's oxygen saturation are essential interventions for a client with pneumonia. Rest helps conserve energy and reduces the workload on the respiratory system, while monitoring oxygen saturation ensures that the client is maintaining adequate oxygen levels, which is crucial in pneumonia.
B. Placing the client on strict fluid restriction is not appropriate for pneumonia. In fact, adequate hydration is important to help thin respiratory secretions and facilitate expectoration.
C. Placing the client on oxygen is often necessary for clients with pneumonia, especially if they are hypoxic or have difficulty maintaining adequate oxygen levels. Supplemental oxygen supports the respiratory system and improves oxygenation.
D. Restricting the client's smoking to 5 cigarettes per day is not an appropriate intervention. Smoking should be completely stopped to help reduce the risk of further respiratory complications. Smoking cessation is a priority in managing respiratory conditions like pneumonia

A. "I will try not to gain weight." B. "I will sleep with the head of my bed elevated." C. "I will drink less fluid." D. "I will consume less caffeine and fewer spicy foods." E. "I will lie down for one half hour after meals."

Correct Answer is ["A","B","D"]

Explanation

A. Maintaining a healthy weight is important in managing a hiatal hernia. Excess weight can increase abdominal pressure, which may worsen symptoms of acid reflux.
B. Sleeping with the head of the bed elevated helps prevent acid reflux and symptoms of heartburn associated with a hiatal hernia. Elevation reduces the risk of stomach contents moving into the esophagus during sleep.
C. Drinking less fluid is not a necessary dietary change for hiatal hernia management. However, clients should avoid consuming large amounts of fluid with meals, as this may exacerbate reflux symptoms.
D. Consuming less caffeine and fewer spicy foods is appropriate because both can irritate the esophagus and increase acid reflux. Caffeine and spicy foods are known to trigger symptoms in individuals with a hiatal hernia.
E. Lying down for one-half hour after meals is not recommended for clients with a hiatal hernia, as it can worsen symptoms of reflux. The client should be advised to wait at least 2–3 hours before lying down after eating.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with pneumonia. Which interventions should the nurse include in the plan of care? (Select All that Apply.)

Correct Answer is ["A","C"]

Explanation

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

A patient has a nasogastric (NG) tube following esophagectomy. Following standards of practice, which of the following postoperative instructions should the nurse question the surgeon about?

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

A patient who is taking NSAIDs to treat arthritis asks the nurse why Cytotec (misoprostol) has also been prescribed. Which explanation by the nurse is accurate?

A 36-year-old patient with suspected gastrointestinal (GI) bleeding undergoes a diagnostic endoscopy which determines the site of bleeding is a duodenal ulcer. The nurse explains to the patient that bleeding ulcers are commonly related to which of the following: