The nurse is caring for a patient and is monitoring the level of consciousness hourly per hospital mandated policy. The nurse initially assesses the patient be awake with forgetfulness and difficulty following commands without prompting or reminders. 1 hour later, the nurse assesses the patient to be sleepy with slow and delayed responses to stimuli. Describe the two assessments of level of consciousness:

Confusion, Lethargic

Confusion, Stupor

Lethargic, Obtunded

Conscious, Confusion

Answer and Explanation

The Correct Answer is A

A. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.

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Correct Answer is C

Explanation

A. While being alert for non-verbal clues for pain or discomfort is important, it does not directly address the risk for ineffective airway clearance.
B. Answering for the client during rounds with the physician may compromise the client's ability to communicate their needs and concerns, which is not appropriate.
C. Assessment of the ability to cough and swallow is crucial for clients who have undergone oral surgery, as it directly relates to their airway clearance and safety in managing secretions.
D. Providing enough time for the client to respond is important for overall communication and comfort but does not specifically address the risk for ineffective airway clearance, which requires more targeted interventions.

A. Applies pressure to all injection sites for 5 minutes B. Monitors telemetry every hour during therapy C. Ensures the client has a fluid intake of 3000 to 5000 mL/day D. Assists the client in all ambulatory activities

Correct Answer is C

Explanation

A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.

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Naxlex Comprehensive Predictor Exams

A client problem of Risk for Ineffective Airway Clearance has been made for a client who has undergone surgery for oral cancer. What should the nurse include in the plan of care?

Correct Answer is C

Explanation

Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Correct Answer is C

Explanation

The nurse is caring for a patient with trigeminal neuralgia. Which medication to treat the patient's pain would the nurse question?

The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

A client, who is receiving intravenous chemotherapy into a peripheral vein, says that the arm burns terribly in and around the intravenous site. What is the nurse's best first action?

The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include?

The nurse prepares to assess the patient's cranial nerves. Which tool is necessary to assess cranial nerve (CN) III (oculomotor)?

The nurse is evaluating a client's response to ondansetron following the administration of chemotherapy. Which finding indicates an expected outcome? The client:

The nurse is performing discharge planning for a client newly diagnosed with type 1 diabetes mellitus. It would be most important for the plan to include:

A client receives chemotherapy with an agent that causes thrombocytopenia. Which intervention is most important to teach the client?