A nurse caring for a client who is at home on hospice care.

Exhibits

At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Client calm not agitated. Grimaces with movement.

Oral mucous membranes dry.

Axillary temp 102 F (38.9 C), client shivering.

Productive cough.

Coarse rhonchi bilaterally. Crackles in bases.

Respirations irregular with periods of apnea

Client resting in recliner. RR 12, regular

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.

No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.

Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.

No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.

Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.

Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.

Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.

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Correct Answer is D

Explanation

A. 18% is inaccurate

B. 44% is inaccurate

C. 36% is inaccurate

D. According to the Rule of Nines:

Each arm is typically assigned 9% (4.5% for each arm). The chest and abdomen together are assigned 18%.

The upper back is assigned 9%.

The lower back is assigned 9%.

Each leg is typically assigned 18% (9% for each leg). Adding these percentages together for the described burns:

9% (each arm) + 18% (chest and abdomen) + 9% (upper back) + 9% (lower back) = 54%

A. "Increase your intake of grapefruit juice." B. "Expect to have increased generalized bruising." C. "Monitor for muscle pain." D. "Take this medication without food if nausea develops."

Correct Answer is C

Explanation

A. "Increase your intake of grapefruit juice."

Grapefruit juice can interact with many medications, including colchicine, potentially increasing the risk of adverse effects or reducing its effectiveness. Therefore, it is not recommended to increase grapefruit juice intake while taking colchicine.

B. "Expect to have increased generalized bruising." Increased bruising is not a common side effect of colchicine.

C. "Monitor for muscle pain."

Colchicine is associated with myotoxicity, which can manifest as muscle pain or weakness. Therefore, the client should be instructed to monitor for signs and symptoms of muscle pain and report them promptly to their healthcare provider.

D. "Take this medication without food if nausea develops."

While colchicine can cause gastrointestinal side effects such as nausea and vomiting, taking it without food may exacerbate these symptoms. It is generally recommended to take colchicine with food to minimize gastrointestinal upset.

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A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has burns on both arms, chest, abdomen and upper and lower back. Utilizing the Rule of Nines, the nurse estimates that the extent of the client's burns is which of the following percentages?

Correct Answer is D

Explanation

A nurse is teaching a client diagnosed with gout about the new prescription for colchicine. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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A nurse caring for a client who is at home on hospice care.

Exhibits

At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.