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 B

Explanation

A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.

A. no bowel sounds noted during the assessment. B. an SPO2 which registers 90% while the client is asleep. C. increasing abdominal distention. D. a small amount of green-tinged fluid from the nasogastric tube.

Correct Answer is C

Explanation

A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.

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Naxlex Comprehensive Predictor Exams

The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:

Correct Answer is B

Explanation

The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:

Correct Answer is C

Explanation

The nurse is planning care that would decrease the risk for infection in a client who is recovering from a colectomy. The nurse would include which intervention(s)? (SELECT ALL THAT APPLY)

A client was recently diagnosed with lung cancer. The nurse is evaluating discharge teaching with the client. Which statement about lung cancer indicates that teaching was effective?

A client has numerous skin lesions. Which one will the nurse evaluate first?

The nurse is giving discharge instructions to a client newly diagnosed with lung cancer. The nurse understands the client requires additional discharge teaching when the client states:

In planning teaching sessions for a client undergoing photodynamic therapy for lung cancer, the nurse should include which statement?

The nurse is caring for a client diagnosed with cancer who is experiencing a decreased nutritional intake due to painful oral lesions. Which intervention would the nurse include in the plan of care?

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 educates a community group regarding measures that will assist in the prevention of skin cancer. Which of the following statements addresses the need for further teaching? "I will: