The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

Start an IV bolus of lactated Ringer's solution.

Stay with the client for the first 15 min of the transfusion.

Obtain the first unit of packed RBCs from the blood bank.

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

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Answer and Explanation

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

A. Start an IV bolus of lactated Ringer's solution: Not Indicated

- The client's medical record does not indicate a need for fluid resuscitation or immediate volume replacement.

B. Stay with the client for the first 15 min of the transfusion: Not Indicated

- There is no mention of a blood transfusion in the provided information. Therefore, staying with the client during a transfusion is not relevant.

C. Obtain the first unit of packed RBCs from the blood bank: Not Indicated

- There is no indication of a need for a blood transfusion in the client's assessment findings.

D. Document the blood product transfusion in the client's medical record: Not Indicated
- Since there is no indication of a blood transfusion, documenting a transfusion is not relevant.

E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: Not Indicated
- While it's important to monitor and maintain the client's blood pressure, the provided information does not suggest that the client's blood pressure is significantly low (90/60 mm Hg) or that they are receiving any infusions that need titration for blood pressure management.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Incorrect. Napping for an hour during the day can disrupt nighttime sleep.

B. Incorrect. Exercising prior to bedtime can stimulate the body and interfere with falling asleep.
C. Correct. Eating a light snack before bedtime can help prevent waking due to hunger during the night.
D. Incorrect. Staying in bed if unable to fall asleep can lead to frustration and associating the bed with wakefulness.

A. "The client might act seductively." B. "The client is overly concerned about minor details." C. "The client exhibits impulsive behavior." D. "The client is exceptionally clingy to others."

Correct Answer is C

Explanation

A. Incorrect. Acting seductively is more characteristic of histrionic personality disorder.
B. Incorrect. Being overly concerned about minor details is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Impulsive behavior, such as reckless spending or self-harm, is a common feature of borderline personality disorder.
D. Incorrect. Being exceptionally clingy to others is not a defining feature of borderline personality disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

Correct Answer is C

Explanation

A nurse is assessing a client who is postoperative following orthopedic surgery.Which of the following findings should the nurse identify as an indication of paralytic ileus?

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?