Which client assessment should a nurse immediately report to the health care provider?

Report of joint pain by a client who recently started taking arthritis medication.

Report of decreased appetite and difficulty sleeping in a recently widowed client.

Weight loss of two pounds in a client admitted in congestive heart failure.

Diminished breath sounds in a client admitted with pneumonia.

Answer and Explanation

The Correct Answer is D

This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.

Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.

Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.

Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.

Normal ranges for vital signs are as follows :

Blood pressure: 90/60 mm Hg to 120/80 mm Hg
Breathing: 12 to 18 breaths per minute
Pulse: 60 to 100 beats per minute
Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)

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Correct Answer is B

Explanation

“My medication will be given at the scheduled times to best manage my pain.” This statement demonstrates understanding of the pain management plan because it shows that the client knows the importance of preventing pain from becoming severe by taking medication regularly. Scheduled administration of analgesics is more effective than administering them on demand.

Choice A is wrong because it implies that the client will wait until the pain is severe before asking for medication, which can make it harder to control.

Choice C is wrong because it suggests that the client expects to receive inadequate pain relief due to their history of opioid abuse, which is not ethical or evidence-based.

Choice D is wrong because it indicates that the client believes they will be denied any narcotics for pain, which is also not ethical or

evidence-based. Clients with a history of opioid abuse can still receive opioids for acute pain, but they may need higher doses or more frequent administration to achieve adequate analgesia.

Normal ranges for vital signs are as follows: respiratory rate 12-20 breaths per minute, heart rate 60-100 beats per minute, blood pressure 120/80 mmHg, temperature 36.5-37.5°C (97.7- 99.5°F).

A. Blurred or cloudy vision. B. Burning sensation in the eye. C. Inability to produce tears. D. A swollen lacrimal gland.

Correct Answer is A

Explanation

Cataracts are a condition where the lens of the eye becomes opaque, causing impaired vision. Blurred or cloudy vision is a common symptom of cataracts.

Some possible explanations for the other choices are:

Choice B. Burning sensation in the eye. This is not a typical symptom of cataracts, but it could indicate an infection, allergy, or dry eye syndrome.

Choice C. Inability to produce tears. This is also not a typical symptom of cataracts, but it could indicate a problem with the lacrimal glands or ducts that produce and drain tears.

Choice D. A swollen lacrimal gland. This is not a symptom of cataracts, but it could indicate an inflammation or infection of the lacrimal gland, which is located near the upper eyelid.

Normal ranges for visual acuity are 20/20 for normal vision and 20/40 for mild impairment. Visual acuity can be measured using a Snellen chart or other methods.

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Which client assessment should a nurse immediately report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has developed a pain management plan for a client who has a history of opioid drug abuse. Which of the following statements by the client demonstrates understanding of the pain management plan?

Correct Answer is B

Explanation

A 68-year-old client diagnosed with cataracts should be assessed for which finding?

Correct Answer is A

Explanation

A nurse is teaching a client about preparation for a barium enema. What client statement indicates the client requires further reinforcement of teaching?

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

Which amount of urine production should the nurse evaluate as adequate output for a typical adult client?

A nurse should include which rationale when instructing a client to avoid sitting with knees crossed?

A nurse is admitting a client with an exacerbation of chronic obstructive pulmonary disease. What signs would the nurse expect to observe with this client? Select all that apply.

A client is to receive 250,000 units of benzathine penicillin. G. The medication is available in a vial containing 300,000 units per milliliter. How many milliliters should a nurse administer?

An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia. Which of the following is the best reason for the assessment findings?