The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermitent suction. The client reports dizziness and tingling in digits. Which assessment finding by the PN should be reported to the healthcare provider?

Hyperactive bowel sounds on assessment.

Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry.

Hypoactive bowel sounds on assessment.

Regular heart rate of 100 beats per minute on telemetry.

Answer and Explanation

The Correct Answer is B

PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.

The other options are not correct because:

A. Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.

C. Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after bowel surgery and do not require immediate intervention.

D. Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.

A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.

B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.

D.Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.

A. Urinary output. B. Blood pressure while standing. C. Ability to swallow. D. Frequency of bowel movements.

Correct Answer is C

Explanation

Choice A rationale:

Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.

Choice B rationale:

Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.

Choice C rationale:

Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.

Choice D rationale:

Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

Correct Answer is C

Explanation

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

A client tells the practical nurse (PN) that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond?

An older adult female asks the practical nurse (PN) if she should get a Herpes zoster (shingles) vaccination because she gets cold sores on her mouth when she is sick or stressed. Which response should the PN provide?

When caring for a child with sickle cell disease, the practical nurse (PN) expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?

A 70-year-old male client who is convalescing from a hip replacement is identified as being at risk for developing a pressure ulcer. Which physical characteristic of aging contributes most to this risk factor?

The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the practical nurse (PN) note as the most significant indicator of possible child abuse?

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.).