A nurse on a medical-surgical unit is caring for a client.
Exhibits
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing dropdown and dropdown
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CVA) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop, characterized by difficulty in lifting the front part of the foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
To calculate the flow rate for an IV fluid bolus, you can use the formula: (Volume in mL * Drop factor) / Time in minutes. For a 200 mL dextrose 5% in water to be administered over 30 minutes with a drop factor of 15 gtt/mL, the calculation would be (200 * 15) / 30, which equals 100 gtt/min.
Correct Answer is A
Explanation
A. Determining what the client already knows about managing diabetes is the initial step in assessing the client's current knowledge and understanding. This helps the nurse tailor the teaching plan to the client's needs and avoid redundancy.
B. Providing access to a video about diabetes may be part of the teaching plan but should come after assessing the client's baseline knowledge.
C. Establishing short-term, realistic goals is important but should follow the assessment of the client's current knowledge and understanding.
D. Evaluating the effectiveness of the client's admission teaching plan is important but should occur after the initial assessment and implementation of a personalized teaching plan.
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