A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:

Exhibits
Which of the following are the most appropriate interventions for this client? Select all that apply.

Encourage the client to increase physical activity and engage with peers.

Suggest the client remain in bed to avoid unnecessary exertion.

Teach the caregiver how to monitor for signs of infection in pressure injuries.

Assist the client in using the restroom to avoid incontinence.

Answer and Explanation

Correct Answer : A,C,D

The correct answers are Choices A, C, and D.

Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.

Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.

Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.

Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.

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Correct Answer is A

Explanation

Choice A rationale

Assessing serum potassium levels every 4 hours is essential for clients receiving insulin to treat hyperkalemia. Insulin promotes the uptake of potassium into cells, potentially leading to hypokalemia. Frequent monitoring ensures prompt detection of abnormal potassium levels, enabling timely intervention.

Choice B rationale

Although glucose monitoring is important, it is not the priority. Insulin administration affects potassium levels more significantly in this scenario, and glucose level fluctuations are typically less life-threatening than potassium imbalances.

Choice C rationale

Monitoring intake and output is standard practice for managing clients with electrolyte imbalances. However, it does not directly address the primary concern of potassium level fluctuations caused by insulin administration.

Choice D rationale

A daily 12-lead electrocardiogram may provide useful information on the cardiac effects of electrolyte imbalances but is less immediate in detecting rapid potassium changes than frequent serum potassium measurements.

A. Document the wound measurements with tunneling. B. Cleanse the wound and discontinue the VAC system. C. Increase the wound VAC suction to eliminate the drainage. D. Consult the wound care specialist to evaluate the wound. E. Reapply the VAC system after irrigating away drainage.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.

Choice B rationale

Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.

Choice D rationale

Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.

Choice C rationale

Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.

Choice E rationale

Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

A nurse is caring for an 84-year-old female client in her home and is discussing caregiver stress with the client’s daughter. Exhibits Select the 3 statements that the nurse should include when discussing caregiver stress with the client’s daughter.

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

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The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.