A nurse is caring for a client in an acute care setting.
Complete the following sentence by using the list of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The client is at risk for hypostatic pneumonia as evidenced by the client's immobility
Rationale
The combination of paraplegia (which leads to limited mobility) and symptoms such as productive cough, tachycardia, and confusion suggest a respiratory issue, likely hypostatic pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing a yellow bracelet is a common practice for identifying clients at risk for falls and is not considered malpractice.
B. Administering potassium via IV bolus can be dangerous, but it is a matter of scope of practice and guidelines rather than malpractice unless done incorrectly.
C. Leaving a nasogastric tube clamped after administering oral medication is an example of malpractice as it could result in aspiration or improper medication absorption.
D. Documenting communication with a provider in the medical record is standard practice.
Correct Answer is A
Explanation
A. A light snack before bedtime, such as one containing tryptophan, can help promote sleep.
B. A 1-hour nap during the day could disrupt nighttime sleep patterns and should be avoided, especially in the late afternoon or evening.
C. Performing exercises prior to bedtime could be stimulating and might interfere with the ability to fall asleep.
D. Staying in bed for an hour if unable to fall asleep can reinforce frustration and poor sleep patterns. Instead, the client should get up and engage in a relaxing activity before trying to sleep again.
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