EDAPT: NCLEX Readiness:
Physiological Adaptation Part 1
The nurse knows that __________ is the priority concern for the client. The nurse's first action is to
__________. Next, the nurse should anticipate a prescription for __________. The nurse should
question the prescription to administer __________. - Answer-Heat stroke
Apply ice and cooling blankets
Administration of cooled intravenous fluids
Acetaminophen
The nurse cares for a client who has been on positive pressure-controlled mechanical ventilation for 24
hours. During the respiratory assessment, the nurse finds an increase in adventitious lung sounds.
Additionally, the nurse notes a temperature of 100 °F (37.8 °C). The client's skin is pale and dry. The
nurse notes a decrease in tidal volume on the ventilator. Which actions should the nurse take next?
Select all that apply. - Answer-Turn the client to one side while maintaining head elevation.
Suction the client to remove excess secretions.
Collaborate with respiratory therapy for chest physiotherapy.
Verify that the head of the bed is elevated at least 30-45 degrees.
The nurse cares for a client who has just completed a hemodialysis session. For each assessment finding
listed, click to indicate whether the assessment finding is expected or concerning at this time. - Answer-
*Expected:*
Temperature 98.6 °F (37 °C)
, Blood pressure 108/78 mmHg
Reported fatigue
Clear lung sounds
Serum sodium 136 mEq/L (reference range 136-145 mEq/L)
*Concerning:*
Serum potassium 5.5 mEq/L (reference range 3.5-5.0 mEq/L)
Serum phosphate 6 mg/dL (reference range 3-4.5 mg/dL)
The nurse follows up with a client who recently started home peritoneal dialysis. Which statements by
the client require immediate follow-up by the nurse? Select all that apply. - Answer-"Sometimes all of
the solution does not come back out, so I have to push the catheter in further and move around to get it
moving."
"My partner helps me get the process started but, since we live together, my partner does not wear a
mask."
The nurse needs to include all of these in the discharge teaching, but should prioritize __________ as
the most important point. The nurse should emphasize the need to call the healthcare provider if the
__________. Additionally, the nurse should remind the client __________. - Answer-Signs of
dehydration
Client gets a headache or feels dizzy
To empty the pouch every time the client's bladder is emptied
The nurse provides education to a client on the correct use of the incentive spirometer (IS). Click to
specify whether the client's actions during the return demonstration indicate the teaching was effective
or ineffective. - Answer-*Effective:*
The client performs 10 breaths in succession once per hour during waking hours.
The client assumes the semi-Fowler's position during use.
Physiological Adaptation Part 1
The nurse knows that __________ is the priority concern for the client. The nurse's first action is to
__________. Next, the nurse should anticipate a prescription for __________. The nurse should
question the prescription to administer __________. - Answer-Heat stroke
Apply ice and cooling blankets
Administration of cooled intravenous fluids
Acetaminophen
The nurse cares for a client who has been on positive pressure-controlled mechanical ventilation for 24
hours. During the respiratory assessment, the nurse finds an increase in adventitious lung sounds.
Additionally, the nurse notes a temperature of 100 °F (37.8 °C). The client's skin is pale and dry. The
nurse notes a decrease in tidal volume on the ventilator. Which actions should the nurse take next?
Select all that apply. - Answer-Turn the client to one side while maintaining head elevation.
Suction the client to remove excess secretions.
Collaborate with respiratory therapy for chest physiotherapy.
Verify that the head of the bed is elevated at least 30-45 degrees.
The nurse cares for a client who has just completed a hemodialysis session. For each assessment finding
listed, click to indicate whether the assessment finding is expected or concerning at this time. - Answer-
*Expected:*
Temperature 98.6 °F (37 °C)
, Blood pressure 108/78 mmHg
Reported fatigue
Clear lung sounds
Serum sodium 136 mEq/L (reference range 136-145 mEq/L)
*Concerning:*
Serum potassium 5.5 mEq/L (reference range 3.5-5.0 mEq/L)
Serum phosphate 6 mg/dL (reference range 3-4.5 mg/dL)
The nurse follows up with a client who recently started home peritoneal dialysis. Which statements by
the client require immediate follow-up by the nurse? Select all that apply. - Answer-"Sometimes all of
the solution does not come back out, so I have to push the catheter in further and move around to get it
moving."
"My partner helps me get the process started but, since we live together, my partner does not wear a
mask."
The nurse needs to include all of these in the discharge teaching, but should prioritize __________ as
the most important point. The nurse should emphasize the need to call the healthcare provider if the
__________. Additionally, the nurse should remind the client __________. - Answer-Signs of
dehydration
Client gets a headache or feels dizzy
To empty the pouch every time the client's bladder is emptied
The nurse provides education to a client on the correct use of the incentive spirometer (IS). Click to
specify whether the client's actions during the return demonstration indicate the teaching was effective
or ineffective. - Answer-*Effective:*
The client performs 10 breaths in succession once per hour during waking hours.
The client assumes the semi-Fowler's position during use.
