The nurse manager on the orthopedic unit is reviewing a report that in

Health Care of the Older Adult NCLEX

Home / Nursing & Allied Health Certifications / NCLEX RN / RN Medical Surgical Nursing

Question 1 of 5.

The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should:

A. Use benchmarking procedures to compare the findings with other nursing units in the hospital.

B. Ask the staff education department to conduct an educational session about preventing pressure ulcers.

C. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.

D. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.

Explanation: A quality improvement plan addresses root causes, proposes solutions, and sets measurable outcomes, effectively reducing pressure ulcer incidence.

Question 2 of 5.

The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following?

A. Obtaining an infusion pump for the medication.

B. Monitoring blood pressure every 4 hours.

C. Monitoring urine output hourly.

D. Obtaining serum potassium levels daily.

Explanation: An infusion pump ensures accurate delivery of nitroglycerin, which requires precise titration. BP monitoring should be more frequent (e.g., every 15-30 minutes), and urine output and potassium levels are not primary concerns.

Question 3 of 5.

A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:

A. Call for the physician.

B. Start an I.V. line.

C. Obtain a portable chest radiograph.

D. Draw blood for laboratory studies.

Explanation: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.

Question 4 of 5.

Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?

A. Administer the medications.

B. Call the physician.

C. Withhold the captopril.

D. Question the metoprolol dose.

Explanation: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.

Question 5 of 5.

A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client?

A. Monitor the laboratory values.

B. Observe neurologic function every 15 minutes.

C. Observe the puncture site for swelling and bleeding.

D. Monitor skin warmth and turgor.

Explanation: Observing the puncture site for swelling and bleeding is critical post-catheterization to detect complications like hematoma or hemorrhage.

Related Questions

A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. In addition, the client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair after her bath, the client complains of severe pain and numbness in her left leg. The nurse should respond immediately by:

Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.

A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2Â°C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50 to 70 mL/hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider:

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:

The nurse is teaching a client and his family about the client's new diagnosis of hemochromatosis. Which of the following details should the nurse include?