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A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

Tell the client's child that they will be reported for maltreatment of the client.

Ask the client's child to provide details regarding the client's fractured arm.

Discuss respite care options with the client's child.

Speak to the client privately.

Provide legal advice to the client regarding power of atorney.

Answer and Explanation

Correct Answer : B,C,D

The correct answers are b, c, and d.

a. It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without

further assessment and evidence.

b. Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.

c. Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.

d. Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.

e. Providing legal advice regarding power of atorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["1.5"]

Explanation

To calculate the required mL of morphine solution needed to administer 30 mg of morphine orally (PO), you can use the following formula:

Volume (in mL) = Amount (in mg) / Concentration (in mg/mL)

In this case, the amount of morphine is 30 mg, and the concentration of the morphine solution is 20 mg/mL.

Volume (in mL) = 30 mg / 20 mg/mL

Volume (in mL) = 1.5 mL

Therefore, the nurse should administer 1.5 mL of the morphine solution to deliver 30 mg of morphine to the client orally.

A. Encourage the client to use the overbed trapeze. B. Maintain abduction of the client's residual limb with a pillow. C. Caution the client to avoid a prone position while in bed. D. Keep a loose, absorbent dressing over the client's surgical site

Correct Answer is A

Explanation

A nurse caring for a client who is 2 days postoperative following an above-the-knee amputation should encourage the client to use the overbed trapeze. This will promote independence and mobility by allowing the client to reposition themselves in bed and perform upper body exercises.

Maintaining abduction of the client's residual limb with a pillow can help prevent contractures, but it does not directly promote mobility.

Cautioning the client to avoid a prone position while in bed is appropriate to prevent pressure injuries and promote healing, but it also does not directly promote mobility.

Keeping a loose, absorbent dressing over the client's surgical site is important for infection control but does not promote mobility.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer morphine 30 mg PO to a client who reports pain. Available is morphine solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.5"]

Explanation

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray, which of the following methods should the nurse use to verify the placement?

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