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

This is because the pH of gastric contents is acidic (less than 5.5) and can indicate that the tube is in the stomach. This method is predictive of the correct placement of a nasogastric tube.

Choice A is wrong because fluoroscopy is not the most reliable method to confirm the correct placement of a nasogastric tube. It is an imaging technique that uses X-rays to show the movement of the tube, but it is not always available or feasible.

Choice C is wrong because injecting air and listening for gurgling sounds is not a reliable method to confirm the correct placement of a nasogastric tube. It can cause false-positive results and does not differentiate between the stomach and the respiratory tract.

Choice D is wrong because observing for bubbles after placing the end of the tube in a cup of water is not a reliable method to confirm the correct placement of a nasogastric tube. It can also cause false-positive results and does not differentiate between the stomach and the respiratory tract.

A. I will eat my breakfast prior to coming in for the study. B. I may need to have laxatives to expel the barium. C. I will receive the barium prior to the study by rectum. D. I will need to lie down during the study while retaining the barium for x-rays.

Correct Answer is A

Explanation

The client should not eat anything before the barium enema, as this could interfere with the visualization of the colon. The client should also take a laxative and an enema the night before the test to clear the bowel of any fecal matter.

Choice B is wrong because the client may need to have laxatives to expel the barium after the test, not before. Barium can cause constipation and impaction if not eliminated promptly.

Choice C is wrong because the client will receive the barium prior to the study by rectum, which is correct. The barium is a contrast agent that helps outline the colon on X-rays.

Choice D is wrong because the client will need to lie down during the study while retaining the barium for X-rays, which is correct. The client may also be asked to change positions to allow different views of the colon.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which technique is most reliable to confirm correct placement of a nasogastric tube prior to initiating tube feedings?

Correct Answer is B

Explanation

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

Correct Answer is A

Explanation

A client states “I don’t want to have surgery.” Which of the following is a therapeutic response to the client?

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 nurse is receiving a client from the post anesthesia unit after a colon resection. What is the first observation the nurse should perform?

When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).

Which client behavior is indicative of hearing loss?

A client has been newly diagnosed with hypothyroidism. What symptoms or signs would be expected with this diagnosis? Select all that apply.

Which abbreviation indicates a medication is to be administered after meals?

Which action is appropriate for a nurse to remove a soiled wound dressing?