A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
Urinary hesitancy
Dysphagia
Swollen gums
Pruritus
The Correct Answer is B
Choice A Reason: This choice is incorrect because urinary hesitancy is not the priority finding for the nurse to address.
Urinary hesitancy is a difficulty or delay in starting or maintaining a urine stream. It may be caused by various factors such as prostate enlargement, urinary tract infection, medication side effects, or psychological issues. It may cause discomfort, pain, or urinary retention, but it does not pose an immediate threat to the client's life.
Choice B Reason: This choice is correct because dysphagia is the priority finding for the nurse to address. Dysphagia is a difficulty or inability to swallow food or liquids. It may be caused by various factors such as stroke, Parkinson's disease, dementia, esophageal cancer, or oral infections. It may cause malnutrition, dehydration, aspiration, or choking, which can lead to serious complications such as pneumonia, sepsis, or death. Therefore, the nurse should assess the client's swallowing function and provide appropriate interventions such as modifying the diet texture, using thickening agents, or teaching swallowing techniques.
Choice C Reason: This choice is incorrect because swollen gums are not the priority finding for the nurse to address. Swollen gums are an inflammation or enlargement of the gingival tissue that surrounds the teeth. They may be caused by various factors such as poor oral hygiene, gum disease, vitamin deficiency, medication side effects, or hormonal changes. They may cause bleeding, pain, or infection, but they do not pose an immediate threat to the client's life.
Choice D Reason: This choice is incorrect because pruritus is not the priority finding for the nurse to address. Pruritus is a sensation of itching that affects the skin. It may be caused by various factors such as dry skin, allergies, eczema, psoriasis, liver disease, or kidney disease. It may cause discomfort, scratching, or skin damage, but it does not pose an immediate threat to the client's life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["24"]
Explanation
- To find the concentration of heparin in the solution, divide the amount of heparin by the volume of D5W: 25,000 units / 500 mL = 50 units/mL
- To find the infusion rate, divide the prescribed dose by the concentration: 1,200 units/hr / 50 units/mL = 24 mL/hr
- Round the answer to the nearest tenth/whole number: 24 mL/hr
Correct Answer is ["167 "]
Explanation
To calculate the dose of enoxaparin, follow these steps:
1) Convert the client's weight from pounds to kilograms:
245 lbs / 2.2046 (kg/lb) = 111.13 kg (rounded to the nearest whole number, it's 111 kg).
2) Multiply the weight in kilograms by the prescribed dose per kilogram:
111 kg x 1.5 mg/kg = 166.5 mg.
Round the answer to the nearest whole number, so the nurse should administer 167 mg per dose of enoxaparin every 12 hours to the client with a pulmonary embolism.
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