The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?

Have the client sign the surgical and transfusion permits.

Notify the healthcare provider of the client's medication history.

Ensure that the potential for bleeding is explained to the client.

Observe the heparin injections sites for signs of bruising.

Answer and Explanation

The Correct Answer is B

A. Having the client sign surgical and transfusion permits is important but not the priority in this situation.

B. Notifying the healthcare provider of the client's medication history, including heparin use, is crucial to ensure appropriate perioperative management and to prevent excessive bleeding during surgery.

C. Explaining the potential for bleeding to the client is important for informed consent but is not the priority in this situation.

D. Observing the heparin injection sites for signs of bruising is important but not the priority compared to notifying the healthcare provider about the client's medication history.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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

Explanation

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

A. Teach importance of medication regimen and follow-up protocol. B. Discuss that partners without similar symptoms may not be infected. C. Emphasize that using safe sex practices removes the risk of STIs. D. Clarify that all STIs are transmitted through sexual intercourse.

Correct Answer is A

Explanation

A. Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread to others. It addresses the immediate health concern and helps prevent further transmission.

B. While partners without symptoms may not show signs of infection, they could still be carriers of gonorrhea and should be tested and treated if necessary.

C. While using safe sex practices can reduce the risk of STIs, it may not completely eliminate the risk, especially if a partner has multiple sexual partners.

D. While sexual intercourse is a common mode of transmission for STIs, not all STIs are transmitted exclusively through sexual intercourse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

Correct Answer is A

Explanation

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendation should the nurse encourage the client to follow?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places It over the wound. Which intervention should the nurse implement next?

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?