A nurse is admitting a client to a medical-surgical unit following a fall at home.

Exhibits

The nurse is discussing the client’s treatment plan with a provider. For each potential provider’s prescription, specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Administer spironolactone

Administer an IV fluid bolus

Obtain an x-ray of the right hip

Administer an iron supplement

Obtain the client’s weight

Administer supplemental oxygen

Answer and Explanation

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

Potential Prescription	Anticipated	Nonessential	Contraindicated
Administer spironolactone			✅
Administer an IV fluid bolus	✅
Obtain an x-ray of the right hip	✅
Administer an iron supplement		✅
Obtain the client’s weight	✅
Administer supplemental oxygen		✅

Choice A: Administer spironolactone

Spironolactone is a potassium-sparing diuretic used to manage heart failure and hypertension. However, the client’s potassium level is elevated at 5.3 mEq/L (normal range: 3.5 to 5 mEq/L) . Administering spironolactone could exacerbate hyperkalemia, leading to dangerous cardiac arrhythmias. Additionally, the client’s low blood pressure (89/60 mm Hg) and dehydration (indicated by dry skin and tenting) make the use of a diuretic inappropriate as it could further lower blood pressure and worsen dehydration .

Choice B: Administer an IV fluid bolus

The client presents with signs of dehydration (dry skin, tenting, low urine output) and hypotension (BP 89/60 mm Hg). An IV fluid bolus is anticipated to restore intravascular volume, improve blood pressure, and address

dehydration . This intervention is crucial to stabilize the client’s hemodynamic status and improve perfusion to vital organs .

Choice C: Obtain an x-ray of the right hip

The client reports pain in the right hip following a fall, which raises the suspicion of a fracture. An x-ray is essential to diagnose any potential fractures or dislocations, which are common in elderly patients after a fall 5.

Prompt imaging will guide appropriate management and prevent further complications .

Choice D: Administer an iron supplement

While the client has a history of iron-deficiency anemia and is on ferrous sulfate, the immediate need for iron supplementation is nonessential in the context of acute management of the fall and dehydration. The client’s hemoglobin (16 g/dL) and hematocrit (47%) are within normal ranges, indicating that anemia is currently well- managed . The focus should be on stabilizing the client’s acute condition.

Choice E: Obtain the client’s weight

Obtaining the client’s weight is anticipated as it is a critical parameter for calculating medication dosages, fluid requirements, and monitoring the client’s overall health status. Accurate weight measurement is particularly important in elderly patients with multiple comorbidities to ensure precise and safe medical management .

Choice F: Administer supplemental oxygen

The client’s oxygen saturation is 95% on room air, which is within the normal range (95-100%) . Therefore, administering supplemental oxygen is nonessential unless there is evidence of hypoxia or respiratory distress. The primary focus should be on addressing dehydration and hypotension.

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Correct Answer is C

Explanation

Choice A reason: Testing new nurses for exposure to tuberculosis

Testing new nurses for exposure to tuberculosis is an example of secondary prevention. Secondary prevention aims to detect and treat diseases early, often before symptoms are present, to minimize serious consequences. This activity involves screening and early detection, which are hallmarks of secondary prevention.

Choice B reason: Providing treatment for clients who have chronic obstructive pulmonary disease

Providing treatment for clients who have chronic obstructive pulmonary disease (COPD) is an example of tertiary prevention. Tertiary prevention focuses on managing existing diseases to prevent complications, reduce disability, and improve quality of life. This includes ongoing treatment and rehabilitation efforts to manage chronic conditions effectively.

Choice C reason: Performing screening for sexually transmitted infections

Performing screening for sexually transmitted infections (STIs) is another example of secondary prevention. Screening programs aim to detect diseases early, often before symptoms appear, to provide timely treatment and prevent further spread. This activity is crucial for early intervention and control of infectious diseases.

Choice D reason: Administering influenza immunizations at a local health fair

Administering influenza immunizations is an example of primary prevention. Primary prevention aims to prevent diseases from occurring in the first place through measures such as vaccinations, health education, and lifestyle modifications. Immunizations are a key component of primary prevention strategies.

A. Consume a high-protein diet. B. You may donate blood 6 months after completing the medication regimen. C. Take acetaminophen every 4 hours, as needed, for discomfort. D. Rest frequently throughout the day.

Correct Answer is D

Explanation

Choice A reason: Consume a high-protein diet

A high-protein diet is not typically recommended for clients with hepatitis B. While protein is essential for overall health, excessive protein intake can put additional strain on the liver, which is already compromised in hepatitis B patients. A balanced diet with adequate protein, carbohydrates, and fats is more appropriate.

Choice B reason: You may donate blood 6 months after completing the medication regimen

Clients with hepatitis B should not donate blood. The hepatitis B virus can be transmitted through blood, and even after completing a medication regimen, the virus can still be present in the blood. Therefore, this statement is incorrect and potentially harmful.

Choice C reason: Take acetaminophen every 4 hours, as needed, for discomfort

Acetaminophen should be used with caution in clients with hepatitis B. The liver metabolizes acetaminophen, and excessive use can lead to liver damage. It is crucial to consult with a healthcare provider before taking any medication, including acetaminophen, to avoid exacerbating liver issues.

Choice D reason: Rest frequently throughout the day

Resting frequently throughout the day is an important part of managing hepatitis B. The liver plays a crucial role in energy metabolism, and when it is compromised, clients may experience fatigue. Adequate rest helps the body recover and manage symptoms more effectively.

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Choice B: Administer an IV fluid bolus

Choice C: Obtain an x-ray of the right hip

Choice D: Administer an iron supplement

Choice E: Obtain the client’s weight

Choice F: Administer supplemental oxygen

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?

Correct Answer is C

Explanation

A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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