Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Solid with red streaks.

Formed but soft.

Brown liquid.

Tarry appearance.

Multiple hard pellets.

Answer and Explanation

Correct Answer : A,C,D,E

A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.

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Correct Answer is C

Explanation

The nurse should first discuss with the client her meaning of heroic measures.

This will help the nurse to understand the client’s wishes and preferences for her care.

Choice A is incorrect because obtaining a do not resuscitate prescription should be done after discussing the client’s wishes and preferences.

Choice B is incorrect because setting up a family conference to discuss the client’s wishes should be done after discussing the client’s wishes and preferences with her.

Choice D is incorrect because consulting the palliative care team about the client’s care should be done after discussing the client’s wishes and preferences with her.

Correct Answer is ["1"]

Explanation

The nurse should instruct the client to take 1 tablespoon within each dose.

Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled “Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL”, the client should take 15 mL of the suspension per dose.

Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.

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Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops. What actions should the nurse take first?

Correct Answer is C

Explanation

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL". How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).

Correct Answer is ["1"]

Explanation

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse is teaching a client how to self-administer subcutaneous heparin injections. Which instruction should the nurse include?

The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube. At checking the restraints, which action is most important for the nurse to take?