The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.

Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above.

Start an IV bolus of lactated Ringer's solution.

Document the blood product transfusion in the client's medical record.

Discard the blood bag in the client's trash can after the transfusion.

Assist with obtaining the first unit of packed RBCs from the blood bank

Monitor the client for the first 15 min of the transfusion.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Tell the client to leave the group if they cannot contribute. Forcing a client to leave due to silence is inappropriate and can increase feelings of isolation and anxiety. Clients should be encouraged to participate at their own pace.
B. Allow the client extra time to think of a response. Some clients may need more time to process thoughts before speaking. Allowing extra time provides a supportive environment and respects the client’s comfort level in participation.
C. Appoint the client to lead the discussion. Assigning a leadership role to a silent client may increase anxiety and discourage participation rather than help them feel included. Participation should be encouraged but not forced.
D. Ask other group members to limit the number of responses. Restricting other members' participation does not address the silent client’s needs and may disrupt group dynamics. Instead, creating an inclusive and supportive environment is key to fostering engagement.

A. Encourage oral fluid intake. B. Administer an enema. C. Irrigate indwelling catheter with 500 mL of fluid. D. Assist the client with a sitz bath. E. Encourage prolonged dangling before ambulation.

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

Explanation

A. Encourage oral fluid intake. The client has pink urine, which may indicate mild hematuria. While the urine output is adequate, increasing fluid intake can help dilute the urine, reduce irritation, and promote overall hydration. Additionally, increased fluid intake can aid in softening stool and preventing further constipation.
B. Administer an enema. The client reports abdominal cramping and a small, hard, painful bowel movement, indicating constipation. Postoperative clients are at risk for constipation due to decreased mobility, opioid pain medications, and anesthesia effects. Administering an enema can help relieve discomfort and promote bowel movements.
C. Irrigate indwelling catheter with 500 mL of fluid. The client's urinary catheter is intact, and there is a consistent urine output of 100 mL/hr. The presence of pink urine does not indicate obstruction requiring catheter irrigation. Irrigation with such a large volume could introduce unnecessary risk and is not warranted at this time.
D. Assist the client with a sitz bath. Sitz baths are typically used for perineal discomfort, such as after perineal surgery, hemorrhoids, or childbirth. There is no indication in the nurse’s notes that the client has perineal pain or a condition requiring a sitz bath.
E. Encourage prolonged dangling before ambulation. The client is already ambulating independently, indicating no significant issues with orthostatic hypotension or weakness. Encouraging prolonged dangling is unnecessary and could delay mobility, which is essential for preventing complications such as constipation and venous thromboembolism.

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The nurse is reviewing the client's medical record. Exhibits For each potential nursing action, click to specify if the action is indicated or not indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a group therapy session and notes a client who remains silent. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Exhibits Select the 2 actions the nurse should prepare to take for the client.

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

Explanation

A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse is unfamiliar with a medication they are preparing to administer to a client. Prior to administering the medication, the nurse should refer to which of the following resources?

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

A nurse is monitoring a client who was admitted for hypocalcemia. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.