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

Nurses' Notes

Day 1, 12:00:

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

The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.

The 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." The 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 the power of attorney.

Answer and Explanation

Correct Answer : B,C,D

It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.

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.

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.

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.

Providing legal advice regarding power of attorney 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 attorney should be assessed before providing such advice.

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Correct Answer is B

Explanation

All of the listed actions can be part of evaluating the effectiveness of a performance improvement program, but identifying data collection methods is the most specific to evaluating the outcomes of the program.

Therefore, the nurse should identify data collection methods to evaluate the effectiveness of the program. Reviewing the facility's policy and procedure manual, defining the problem, and performing chart audits are all important steps in the performance improvement process, but they do not specifically address the evaluation of the program's effectiveness.

A. You should eat a protein-rich diet during the collection period. B. You should record your blood glucose level each time you void. C. You can begin a collection of urine after discarding your first-morning void. D. You can cleanse your perineal area with an antiseptic towel each time before you void.

Correct Answer is C

Explanation

A 24-hour creatinine clearance test is used to evaluate how well the kidneys are functioning by measuring the amount of creatinine in the blood and urine over a 24-hour period. During the test, the client is asked to discard their first-morning void and then collect all urine for the next 24 hours.
Option A is incorrect because a protein-rich diet can aﬀect the creatinine levels in the urine, which can result in inaccurate test results. Therefore, the nurse should advise the client to avoid a protein-rich diet during the collection period.
Option B is incorrect because blood glucose levels are not relevant to a 24-hour creatinine clearance test. Therefore, the nurse should not ask the client to record their blood glucose level each time they void.
Option D is incorrect because using an antiseptic towel to cleanse the perineal area can also aﬀect the test results by introducing contaminants into the urine sample. Therefore, the nurse should advise the client to cleanse the perineal area with soap and water or an alcohol wipe.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings as the priority to report to the provider?

A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take?

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?