NCLEXRNTESTBANKFOR - Thenursereceivesaclientfromthepostanesthesiacar...

NCLEXRNTESTBANKFOR

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Thenursereceivesaclientfromthepostanesthesiacareunitfollowingaleftfemoral-popliteal bypassgraftprocedure.Whichofthefollowingassessmentsrequiresimmediatenotificationofthe healthcareprovider?•Leftfootiscooltothetouch •AbsentleftpedalpulseusingDoppleranalysis •Inabilitytopalpatetheleftpedalpulse •Acutepainintheleftlowerleg Althoughtheinabilitytopalpatetheleftpedalpulse,acoolextremity,andincreasedpainintheleft lowerlegareimportantfindings,theyallrequireadditionalnursingassessmentpriortocontactingthe healthcareprovider.Inclientswithoutpalpablepedalpulses,thenextstepintheassessmentisto performaDoppleranalysis.TheinabilitytolocatetheleftpedalpulseusingtheDoppleranalysis requiresimmediatelynotifyingthehealthcareprovider.Ref#1028

There'sanewmedicationorderthatreads:"administer1gttciprofloxacin

solutionODQ4h"Whatactionshouldthenursetake?Calltheprescribertoclarifyandrewritetheorder Abbreviations,symbolsanddosedesignationscanbemisinterpretedandleadtomedicationerrors."OD" canmean"righteye"(oculusdexter)or"oncedaily";itshouldneverbeusedwhencommunicating medicalinformation.Theabbreviation"Q"shouldbewrittenoutas"every."Although"gtt"isnotonthe official"DoNotUseList",it'sbesttouse"drop"instead.Askingothernursestointerpretanorderisa potentiallydangerous"workaround."Thenurseshouldcallthehealthcareproviderwhoprescribedthe medicationandclarifytheorder.Ref#1440 Whichindividualisatgreatestriskforthedevelopmentofhypertension?45year-oldAfrican-Americanattorney TheincidenceofhypertensionisgreateramongAfrican-AmericansthanothergroupsintheUnitedStates.TheincidenceamongtheHispanicpopulationisrising.Ref#2446 Awoman,whodeliveredfivedaysagoandwhohadbeendiagnosedwith pregnancyinducedhypertension(PIH),callsahospitaltriagenursehotlineto askforadvice.Shestates,"Ihavehadtheworstheadacheforthepasttwodays.ItpoundsandbythemiddleoftheafternooneverythingIlookatlookswavy.NothingIhavetakenhelps."Whatshouldthenursedonext?Asktheclienttostayontheline,gettheaddress,andsendanambulancetothehome 2 / 4

Thewomanisatriskforseizureactivity.Theambulanceneedstobringthewomantothehospitalfor evaluationandtreatment.Forat-riskclients,PIHmayprogresstopreeclampsiaandeclampsiapriorto, during,orafterdelivery;thismayoccurupto10daysafterdelivery.Ref#2065 Aclientexpressesangerwhenacalllightisnotansweredwithinfiveminutes.Theclientdemandedablanket.Howshouldthenurserespond?"Iseethisisfrustratingforyou.Ihaveafewminutessolet'stalk." Thisisthebestresponsebecauseitgivescredencetotheclient'sfeelingsandthenconcerns.Tosay"let's talk"andaskawhyquestionisnotatherapeuticapproachbecauseitdoesnotacknowledgeorvalidatethe client'sfeelings.Toapologizeandnotnoticetheclient'sfeelingsisinappropriate.Tosayitcouldhave waitedafewminutesisrudeandnon-acceptingoftheclient'sverbalizedneeds.Ref#2134 Theclientisadmittedtoanambulatorysurgerycenterandundergoesaright inguinalorchiectomy.Whichoptionistheprioritybeforetheclientcanbe dischargedtohome Post-operativepainismanaged Anorchiectomyisthesurgicalremovalofoneorbothtesticles.Itisusuallyperformedtotreatcancer (testicular,prostateorcancerofthemalebreast),butitmayalsobeperformedtopreventcancer(withan undescendedtesticle.)Duetothelocationoftheincision,painmanagementisthepriority.Mostmenwill beabletoeatregularlywhentheygethome;theyshouldatleasttolerateliquidsbeforedischarge.It's importantthattheclientisabletogetupandwalkwithassistance,butthisisnotthepriority.Psychologicalcounselingmaybeneededaspartoflong-termaftercare,butthisisnotanimmediatepriority.Ref#1524 Anurseisteachingagroupofadultsaboutmodifiablecardiacriskfactors.Whichofthefollowingshouldthenursefocusonfirst?Smokingcessation Smokingcessationisthepriorityforclientsatriskforcardiacdisease.Smoking'seffectsresultin reductionofcelloxygenationandconstrictionofthebloodvessels.Alloftheotherfactorsshouldbe addressedatsomepointintime.Ref#1721 Theclinicnurseisassistingwithmedicalbilling.ThenurseusestheDRG (DiagnosisRelatedGroup)manualforwhichpurpose?Determinereimbursementforamedicaldiagnosis DRGsarethebasisofprospectivepaymentplansforreimbursementforMedicareclients.Other insurancecompaniesoftenuseitasastandardfordeterminingpayment.KEYWORDSDRG diagnosisrelatedgroup reimbursement 3 / 4

Ref#1328 Anurseisplanningcarefora2year-oldhospitalizedchild.Whichissuewill producethemoststressatthisage?SeparationanxietyWhileatoddlerwillexperienceallof thestresses,separationfromparentsisthemajorstressor.Separationanxietypeaksinthetoddleryears.Ref#2319 Thenurseisreviewingthelaboratoryresultsforseveralclients.Whichofthe laboratoryresultindicatesaclientwithpartlycompensatedmetabolicacidosis?PaCO230mmHg Metabolicacidosiscanbecausedbymanyconditions,includingrenalfailure,shock,severediarrhea, dehydration,diabeticacidosis,andsalicylatepoisoning.Withmetabolicacidosis,youshouldexpecta lowpH(lessthan7.35)andalowHCO3(lessthan22mEq/L.)Compensationmeansthebodyistrying togetthepHbackinbalance;therefore,apuremetabolicacidosisshouldelicitacompensatory decreaseinPaCO3(normalis35-45mmHg.)Thehemoglobiniswithinnormallimits(WNL)for bothmalesandfemales.ThechlorideandsodiumresultsarealsoWNL.Ref#2391 Aclientwithadiagnosisofmethicillin-resistantStaphylococcusaureus(MRSA) hasdied.Whichtypeofprecautionsisappropriatetousewhenperforming postmortemcare?ContactprecautionsTheresistantbacteriaremainaliveforuptothreedays aftertheclientdies.Therefore,contactprecautionsmuststillbeused.Thebodyshouldalsobelabeledas MRSA-contaminatedsothatthefuneralhomestaffcanprotectthemselvesaswell.Gownandglovesare required.Ref#1436 Aclienthasachesttubeinsertedimmediatelyaftersurgeryforaleftlower lobectomy.Duringtherepositioningoftheclientduringthefirstpostopcheck, thenursenotices75mLofadark,redfluidflowingintothecollectionchamber ofthechestdrainsystem.Whatistheappropriatenursingaction?ContinuetomonitortherateofdrainageItisnotunusualforbloodtocollectinthechestandbereleased intothechestdrainwhentheclientchangespositionthissoonaftersurgery.Thedarkcoloroftheblood indicatesitisnotactivebleedinginsideofthechest.Sanguinousdrainageshouldbeexpectedwithinthe initial24hourspostop,progressingtoserosanguinousandthentoaseroustype.Ifthedrainageexceeds 100mL/hr,thenurseshouldcallthesurgeon.Ref#1623Aclientistransportedtotheemergencydepartmentafteramotor vehicleaccident.Whenassessingtheclient30minutesafteradmission,thenurse notesseveralphysicalchanges.Whichfindingwouldrequirethenurse's immediateattention?Trachealdeviation Trachealdeviationisasignthatamediastinalshifthasoccurred,mostlikelyduetoatension pneumothorax.Airescapingfromtheinjuredlungintothepleuralcavitycausespressuretobuild, collapsingthelungandshiftingthemediastinumtotheoppositeside.Thisobstructsvenousreturntothe heart,leadingtocirculatoryinstabilityandmayresultincardiacarrest.Thisisamedicalemergency,

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