A nurse is assisting in the care of a client.

Nurses' Notes Day 1 0800:

Client is alert and oriented

Breath sounds are clear and present throughout. Denies tobacco use.

Client lives in a 20-year-old, one-story house with their partner. Client reports they just returned from an 8-hr car trip. Client eats a high fiber diet and drinks 2,000 mL of

fluid/day.

Day 1,1000:

2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf.

Calf circumference:

Left: 40 cm (15.8 in)

Right: 38.1 cm (15 in)

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing:

lead poisoning

pneumonia

atherosclerosis

constipation

pulmonary embolism

Answer and Explanation

The Correct Answer is B

The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.

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Correct Answer is B

Explanation

A. Standing close to the patient is a recommended practice to maintain proximity and control during patient transfers. This action is appropriate and does not require
intervention.
B. Twisting at the torso can lead to strain or injury to the nurse's back. It is essential to avoid twisting while performing patient transfers to maintain proper body mechanics and prevent injury.
C. Maintaining a wide base of support is important for stability and balance during patient transfers. This action is appropriate and promotes safe transfer techniques.
D. Using proper body mechanics is crucial for preventing injury during patient transfers.

However, the specific concern in this scenario is twisting at the torso, which can lead to strain or injury, rather than overall body mechanics.

A. Every 30 minutes B. Every 180 minutes C. Every 60 minutes D. Every 120 minutes

Correct Answer is D

Explanation

A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.

C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may

still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.

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Naxlex Comprehensive Predictor Exams

While supervising a student who is manually transferring a patient from bed to chair, a nurse intervenes when the student transfers the patient while

Correct Answer is B

Explanation

The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?

Correct Answer is D

Explanation

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