The nurse is reviewing the female client's medical record.

The nurse is planning care for the client.

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Administer regular insulin.

Place client on 1,500 mL fluid restriction.

Increase supplemental oxygen to keep oxygen saturation greater than or equal to 959%.

Obtain sputum culture.

Answer and Explanation

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

• Administer regular insulin: The client’s glucose increased from 120 mg/dL to 195 mg/dL, which is a common stress response in infection. Short-acting insulin may be anticipated to manage hyperglycemia during acute illness. Controlled glucose levels help reduce infection complications and support healing in clients with type 2 diabetes.

• Place client on 1,500 mL fluid restriction: The client shows signs of dehydration risk, including thirst, fever, and increased BUN at 25 mg/dL. With infection and fluid losses from fever, a restriction would worsen hydration status. The client is already receiving IV fluids to maintain volume and support perfusion, so limiting fluids would be harmful.

• Increase supplemental oxygen to ≥95%: The client’s oxygen saturation is 89% on 2 L/min, which is below target and indicates worsening oxygenation. Increasing oxygen flow is appropriate to improve gas exchange in pneumonia and COPD exacerbation. Maintaining higher saturations prevents respiratory fatigue and tissue hypoxia.

• Obtain sputum culture: The client has fever, productive cough with yellow sputum, and chest X-ray-confirmed pneumonia. A sputum culture helps identify the causative organism and guide antibiotic therapy. Culture results can optimize treatment effectiveness and prevent antibiotic resistance.

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Correct Answer is D

Explanation

A. Compensation: Compensation involves emphasizing a strength to make up for a perceived weakness or deficiency. Preparing a deceased partner’s favorite meals does not serve to offset a personal deficiency, so this is not the correct defense mechanism.

B. Dissociation: Dissociation is the temporary detachment from reality or identity to cope with stress or trauma. Cooking familiar meals does not indicate a detachment from reality; the client is fully aware of their actions and circumstances.

C. Rationalization: Rationalization involves creating logical explanations to justify unacceptable behaviors or feelings. Cooking meals for a deceased partner is not an attempt to justify behavior but a coping mechanism, so rationalization does not apply.

D. Denial: Denial is a defense mechanism in which a person refuses to accept reality or facts to avoid emotional pain. Continuing to cook meals for a deceased partner reflects the client’s difficulty accepting the loss, making denial the most appropriate identification of their behavior.

A. Extend the client's legs above heart level. B. Place the client in a low-fowler's position. C. Instruct the client to perform the Valsalva maneuver. D. Apply a dry gauze dressing to the incision.

Correct Answer is B

Explanation

A. Extend the client's legs above heart level: Elevating the legs may improve venous return but does not reduce tension on the abdominal incision or help prevent further dehiscence. It does not address the immediate concern of protecting the surgical site.

B. Place the client in a low-fowler's position: Positioning the client in a low-Fowler’s position (head of bed at 15–30 degrees) helps reduce intra-abdominal pressure on the incision and prevents further separation of the wound edges. This positioning supports comfort and minimizes strain while preparing for dressing application or further intervention.

C. Instruct the client to perform the Valsalva maneuver: Asking the client to strain or hold their breath increases intra-abdominal pressure, which can worsen dehiscence and increase the risk of evisceration. This action is unsafe and should be avoided.

D. Apply a dry gauze dressing to the incision: Applying a dry dressing alone does not protect the exposed tissue and may increase the risk of infection if evisceration occurs. The initial priority is to reduce tension on the wound by positioning before implementing sterile protective measures, such as a saline-moistened sterile dressing if necessary.

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Naxlex Comprehensive Predictor Exams

A nurse is counseling a client whose partner has recently died. The client reports continuing to cook their partner's favorite meals. The nurse should identify that the client is using which of the following defense mechanisms?

Correct Answer is D

Explanation

A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open. "The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is teaching a client about smoking cessation. Which of the following client statements should the nurse identify as an understanding of the teaching?

A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?

A nurse is teaching a client who is to start taking phenelzine for major depressive disorder. Which of the following foods should the nurse teach the client to avoid consuming while taking this medication?

A nurse is caring for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder?

A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client on the medical surgical unit Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider?