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Admission Assessment Day 1, 1000:

An older adult client was transferred to the ICU after they developed a fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty. The client is alert and oriented to person, place, and time. The client's partner is at the bedside.

Past Medical History: hypertension, congestive heart failure, Parkinson's disease Allergies: penicillin (anaphylaxis)

Social History: The client has visual loss but didn't bring their glasses. The client is hard of hearing. Hearing aids in place.

Which of the following actions should the nurse take? Select all that apply.

Request that the client's family bring the client's eyeglasses from home.

Reorient the client often.

Acknowledge the client's feelings.

Provide the client with information about what to expect during their care.

Write the full date on the client's whiteboard.

Ask the client's partner to stay with the client as much as possible.

Maintain a well-lit environment.

Request that the client have the same caregivers with every shift.

Answer and Explanation

Correct Answer : A,B,C,D,E,G

1. 1. Request that the client's family bring the client's eyeglasses from home: This is important to ensure that the client has optimal vision and can see clearly, considering their visual loss. Having their eyeglasses will improve their ability to communicate and understand their surroundings.
  2. Reorient the client often: Reorientation is important for clients who may be disoriented due to their medical condition or unfamiliar environment. Regularly reminding the client of their location, date, and situation can help them maintain orientation.
  3. Acknowledge the client's feelings: Acknowledging and validating the client's feelings can help establish rapport and promote a therapeutic relationship. It shows empathy and understanding, which can contribute to the client's overall well-being.
  4. Provide the client with information about what to expect during their care: Providing information to the client about their care helps promote autonomy and active participation in their own healthcare. It can reduce anxiety and improve the client's overall experience.
  5. Write the full date on the client's whiteboard: Clearly documenting the full date on the client's whiteboard helps the client stay oriented to the current date and time.
  6. Maintain a well-lit environment: Ensuring a well-lit environment is important, especially for clients with visual impairment. Sufficient lighting can enhance the client's ability to see and navigate their surroundings.

It's worth noting that while asking the client's partner to stay with the client as much as possible may be beneficial, it may not always be feasible or within the nurse's control. Additionally, requesting the client to have the same caregivers with every shift may not be possible due to staffing constraints.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The nurse should intervene when the AP raises all four side rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.

A. Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensure stability.

B. Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.

C. Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.

It's important to promote mobility and independence for the client while ensuring their safety.

A. Oxygen saturation level B. Tremors C. Respiratory rate D. Heart rate E. Current level of consciousness F. Chronic health condition

Correct Answer is ["A","C","D"]

Explanation

A.The client's complaint of upper chest discomfort and coughing up thick clear sputum suggests a potential respiratory issue. Checking oxygen saturation is crucial to assess for possible respiratory distress or hypoxia.

B.Tremors are a chronic symptom associated with Parkinson's disease in this client. While monitoring tremors is important for assessing Parkinson's disease management, they are not an acute issue requiring immediate follow-up in this scenario.

C.Coughing up thick clear sputum and upper chest discomfort indicate potential respiratory distress or infection. Monitoring the respiratory rate helps assess the severity of respiratory distress or compromise.

D.Heart rate is a vital sign that can indicate cardiovascular status and response to the client's reported symptoms of feeling bad. Elevated heart rate may indicate stress, pain, or cardiac involvement.

E.The client is reported as alert and oriented to self. While changes in level of consciousness are always important to monitor, the client's current alert and oriented state suggests no immediate acute change.

F.Chronic health conditions such as Parkinson's disease and anxiety are part of the client's history but are not acute findings that require immediate follow-up compared to the acute symptoms of upper chest discomfort and respiratory distress reported.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Correct Answer is D

Explanation

Correct Answer is ["A","C","D"]

Explanation

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A charge nurse is making assignments for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)