The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement?

Wake all the clients and instruct them to go to dining area for medication administration.

Allow the clients to sleep until a third staff person can assist with unit activities.

Explain to the clients that it will be necessary to cooperate until another RN arrives.

Ask the PN to administer medications as clients are awakened so both nurses are available.

Answer and Explanation

The Correct Answer is D

A. Wake all the clients and instruct them to go to dining area for medication administration: Waking all clients at once without adequate staffing may create safety risks and chaos, especially on a mental health unit where supervision is essential.

B. Allow the clients to sleep until a third staff person can assist with unit activities: Delaying medication administration could compromise timely treatment and therapeutic outcomes, making this an unsafe approach.

C. Explain to the clients that it will be necessary to cooperate until another RN arrives: While client communication is important, it does not address the immediate need for safe medication administration and supervision.

D. Ask the PN to administer medications as clients are awakened so both nurses are available: Delegating medication administration to the PN while clients are awakened in a staggered, controlled manner ensures timely delivery of medications, maintains client safety, and allows the nurse to supervise and manage the unit effectively during a staffing shortage.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Prone: Prone positioning limits assessment of spinal curvature, extremity alignment, and body symmetry because the client is lying on the abdomen, which can obscure certain postural deviations.

B. Sims: Sims position is primarily used for rectal or vaginal procedures and does not provide a full view of overall body alignment, making it less ideal for assessment purposes.

C. Supine: Supine position allows the client to lie flat on the back with the body fully supported. This position provides the best view of the head, neck, spine, shoulders, hips, and extremities for a comprehensive assessment of body alignment.

D. Fowlers: Fowlers position elevates the head and torso, which may alter natural spinal alignment and obscure an accurate assessment of posture and symmetry compared with a flat, supine position.

A. IV site without redness or swelling B. Temperature: 98.8° F (37.1° C) C. Respirations: 28 breaths/minute D. Heart rate: 92 beats/minute E. Taking shallow breaths F. Alert and oriented to person, place, time and situation G. Pain 8 on a 0 to 10 scale H. Blood pressure: 138/82 mm Hg I. Blood pressure: 138/82 mm Hg

Correct Answer is ["C","E","G"]

Explanation

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the body alignment of an immobilized client. Which is the best client position for the nurse to obtain an accurate assessment?

Correct Answer is C

Explanation

Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

Correct Answer is ["C","E","G"]

Explanation

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Patient Data Exhibits The nurse needs to determine the priority assessment before administering morphine. Select from Word Choices to complete the sentence. Before administering morphine, the most important assessment to perform is to check the client's ______________

A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?

The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?