A nurse case manager is reviewing the electronic medical record of a postoperative client. Click to highlight the findings that require follow-up by the case manager. To deselect a finding, click on the finding again.

Exhibit 1 Nurses' Notes 1315:

Client is postoperative following an open cholecystectomy, Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment

Plan of Care

1300:

Case management referral for discharge planning.

Client will need home health referral for dressing changes Client to follow up with the provider at the clinic in 1 week.

Client reports being unable to find transportation to follow-up appointment

Client expresses concern regarding the cost of prescription medications

Answer and Explanation

The Correct Answer is ["A"]

The nurse should always be aware of his or her role as the client's advocate. This includes notifying the provider or nurse manager of ant concerns that may interfere with management. This enables the client to get the necessary help and hence improving the chance of health restoration.

Client reporting being unable to find transportation to follow-up appointment is a potential barrier to the client's ability to adhere to their postoperative care plan, specifically their follow-up appointment. Lack of transportation may result in the client missing important postoperative evaluations and assessments, which could impact their recovery and overall outcome.

Client expresses concern regarding the cost of prescription medications does not require immediate follow-up by the case manager unless there are specific interventions or resources the case manager can provide to address the client's concerns.

Case management referral for discharge planning, home health referral for dressing changes, and client to follow up with the provider at the clinic in 1 week-These components of the plan of care have already been initiated or established and do not require further immediate follow-up by the case manager. They represent ongoing aspects of postoperative care management.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

The client with slurred speech and confusion could be experiencing a stroke. Recognition of a stroke is an emergency as some forms of stroke requires immediate intervention that is only amenable within a specific time period.

A. A closed femur fracture may have bleeding and other neurovascular damage but this is not as life threatening as a stroke

B. Superficial burns of 10% is likely to have severe pain. The extent of dehydration is minimal

C. Severe vomiting and diarrhea with tachycardia is a sign that the body is compensating for the fluid loss at this point and, therefore, not of highest priority.

A. Erythema on the skin surrounding a client's wound B. Deep red color on the center of a client's wound C. Increase in serosanguineous exudate from a client's wound D. Inflammation noted on the tissue edges of a client's wound

Correct Answer is B

Explanation

Signs of wound healing include epithelialization, formation of granulation tissue and minimal wound drainage. A deep red color at the center is a sign of granulation

A. Erythema on the surrounding skin is a sign of infection

C. Increased exudate is a sign of infection

D. Inflammation of the wound edges is also a sign of infection

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

Correct Answer is B

Explanation

A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include?

A nurse is delegating care for a client. Exhibit 1 Nurses' Notes 1000: Client has right sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3tasks the nurse should assign to assistive personnel.

A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?

A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?

A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?

A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?

A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy? (Select all that apply.)

A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?