The nurse is continuing to care for the client.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° F). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Day 1, 0930:. Oxygen saturation 97% on room air.
Temperature (oral) 37.1° C (98.8° F). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 99% on room air.
Drag words from the choices below to fill in each blank in the following.
sentence.
The client is at greatest risk for developing Target 1 and Target 2. Conditions.

Placental abruption.

Cervical insufficiency.

Seizures.

Hypoglycemia.

Heart failure.

Answer and Explanation

Correct Answer : C,E

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Correct Answer is A

Explanation

The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.

A. Request a provider to evaluate the client in person every 36 hr. B. Document the client's behavior every 15 min. C. Ensure that the prescription for restraints be renewed every 6 hr. D. Plan to monitor the client every 30 min while restrained.

Correct Answer is B

Explanation

Choice A rationale:

Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.

Choice B rationale:

Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.

Choice C rationale:

Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.

Choice D rationale:

Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is A

Explanation

A nurse in an acute care mental health facility is placing a client in seclusion and restraints.Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.Which of the following actions should the nurse include in the plan?

A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome.Which of the following recommendations should the nurse include?

A nurse in an outpatient mental health clinic is assessing an adolescent client.The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.Which of the following clients should the nurse instruct the AP to report to the nurse?

A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hr ago. Which of the following findings reported by the parent is the nurse's priority?

A nurse is caring for a client on a psychiatric unit. Exhibits For each potential action, click to specify if the action is indicated or. contraindicated for the client.