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A nurse is collaborating with the interprofessional team and reviewing a client's electronic medical record of a post-operative client.

Exhibits

Click to highlight the findings that the nurse should recommend be addressed by the case manager. To deselect a finding, click on the finding again.

Nurses' Notes

1315:

Client is postoperative following an open cholecystectomy. Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment.

Plan of Care

1300:

Case management referral for discharge planning. Client will need home health referral for dressing changes. Client to follow up with the provider at the clinic in one week.

Client's partner is at bedside

dressing intact

small amount of serosanguineous drainage on dressings

reports pain as 5

Client requests a dose of their pain medication

expresses concern regarding the cost of prescription medications

unable to find transportation

home health referral

Answer and Explanation

The Correct Answer is ["D","E","F","G","H"]

Rationale

Client reports pain as 5 on a scale of 0 to 10. The case manager can work with the healthcare team to ensure adequate pain management strategies are in place.
Client requests a dose of their pain medication. This indicates ongoing pain and the need for effective pain management.
Client expresses concern regarding the cost of prescription medications. The case manager can assist with identifying affordable medication options or connecting the client with financial assistance programs.
Client reports being unable to find transportation to follow-up appointment. The case manager can help arrange transportation or connect the client with community resources that can provide transportation assistance.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.

A. Establishing the priorities of client care. B. Comparing the client's current laboratory values to previous results. C. Asking the client about the presence of pain. D. Reinforcing teaching about the client's diagnosis.

Correct Answer is D

Explanation

A. Establishing the priorities of client care is part of the planning phase, not the implementation phase.
B. Comparing laboratory values is an assessment activity that occurs before planning and implementing care.
C. Asking the client about pain is an assessment activity used to gather information rather than an implementation task.
D. Reinforcing teaching about the client's diagnosis is an action that occurs during the implementation phase, as it involves executing the care plan and providing direct client education.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a dressing change for a client who has a nondraining, stage III pressure ulcer that is infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Correct Answer is D

Explanation

A nurse is assisting with the discharge of a client who is postoperative following a total knee arthroplasty. The client lives alone and does not have any friends or relatives who live close by. Which of the following actions should the nurse plan to take?

A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?

A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

The nurse is assisting in the care of clients during a mass casualty event. Exhibits For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.

A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

A nurse is assisting in the review of infection control precautions implemented by staff in a facility. Exhibits Select 2 client situations that require follow-up by the infection control nurse.