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

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Correct Answer is D

Explanation

The correct answer is choice D - Bilateral lung sounds.

Choice A rationale:

Heart sounds. While assessing heart sounds is crucial, the question specifically mentions complications of left-sided heart failure, which primarily affects the lungs. Therefore, assessing lung sounds is a higher priority in this situation.

Choice B rationale:

Mood and affect. While assessing the client's mood and affect is important for holistic care, it is not the most critical assessment to implement first in the case of left-sided heart failure complications.

Choice C rationale:

Chest pain. Although chest pain may be a symptom of left-sided heart failure complications, assessing bilateral lung sounds takes precedence as it directly relates to the client's respiratory status.

Choice D rationale:

Bilateral lung sounds. In left-sided heart failure, fluid can accumulate in the lungs, leading to pulmonary congestion and impaired gas exchange. Therefore, assessing lung sounds helps identify any respiratory distress early on, allowing prompt intervention and prevention of further complications.

A. Dim the lights in the room and close the door. B. Guide the client through slow, rhythmic breathing. C. Turn the television on to the client's favorite show. D. Obtain a prescription for a higher dose of pain medication.

Correct Answer is B

Explanation

This is the best action for the PN to use in assisting this client to deal with his pain because it provides a non-pharmacological method of pain relief that can enhance the eﬀect of the opioid analgesic. Slow, rhythmic breathing can help the client relax, distract from the pain, and increase oxygenation and blood ﬂow.

A. Dimming the lights in the room and closing the door may not be enough to help the client deal with his pain and may not address his psychological or emotional needs.

C. Turning the television on to the client's favorite show may not be eﬀective in helping the client deal with his pain and may be distracting or irritating for him.

D. Obtaining a prescription for a higher dose of pain medication may not be necessary or appropriate for this client and may increase the risk of side eﬀects or dependence. The PN should assess the client's pain level and response to the current dose before requesting a change in medication.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting with the admission of a client with complications of left- sided heart failure. Which focused assessment should the PN implement first?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

A male preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now. How should the PN respond?

A client with urinary and fecal incontinence has an increased risk for developing a sacral pressure ulcer. Which information should the practical nurse (PN) give the unlicensed assistive personnel (UAP) who is assisting with the care of the client?

The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?