A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

Bradycardia.

Bigeminal.

Dysrhythmia.

Tachycardia.

Answer and Explanation

The Correct Answer is D

The client would most likely exhibit tachycardia, which is an abnormally fast heart rate. Fever and infection can both cause an increase in heart rate as the body tries to fight oﬀ the infection. Severe pain can also cause an increase in heart rate due to the body's stress response. Therefore, it is likely that the client would have a fast pulse rate, or tachycardia.

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Correct Answer is C

Explanation

A diet high in protein can help maintain skin integrity in older adults. Protein is essential for tissue repair and wound healing. The other options may not be as effective in maintaining skin integrity. For example, repositioning the client every 3 hours may not be frequent enough to prevent pressure ulcers. Applying cornstarch to keep the skin dry may not be the best option as it is important to keep the skin moisturized. Massaging bony prominences to promote circulation may not be recommended as it could cause damage to fragile skin.

A. The client will perform four to five isometric squeezes for 5 to 10 seconds. B. The client will empty her bladder completely each time she voids. C. The client will improve her incontinence within one month. D. The client will stop the ﬂow of urine when voiding.

Correct Answer is A

Explanation

Stress urinary incontinence is the involuntary loss of urine during physical activity such as coughing, sneezing, or exercising. It is often caused by weakness of the pelvic ﬂoor muscles and/or the urethral sphincter. An appropriate outcome for a client with this condition would be to improve the strength of these muscles. Performing isometric squeezes, also known as Kegel exercises, can help strengthen the pelvic ﬂoor muscles and improve sphincter competence. This can help reduce or prevent episodes of incontinence.

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A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

The nurse is identifying outcomes for a client with the nursing diagnosis of Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

Correct Answer is A

Explanation

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