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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 C

Explanation

This response demonstrates a therapeutic and non-judgmental approach, allowing the client to express their concerns, fears, or reasons for refusing to learn how to self-administer insulin. It promotes open communication and understanding between the nurse and the client, providing an opportunity to address any misconceptions, fears, or barriers the client may have. By actively listening to the client's perspective, the nurse can better tailor the education and support provided, ultimately helping the client make informed decisions regarding their healthcare.

A. Administer an oral contrast solution. B. Ensure that the client gave informed consent. C. Inform the client the procedure will take 60 min. D. Ensure that the client's bladder is full.

Correct Answer is B

Explanation

Before any invasive procedure, it is essential to ensure that the client has given informed consent. Informed consent involves providing the client with detailed information about the procedure, its risks and benefits, and alternatives. The client should have the opportunity to ask questions and fully understand the procedure before giving consent.

Oral contrast solutions are typically used for imaging procedures such as CT scans or X-rays, not for esophagogastroduodenoscopy. This procedure involves the insertion of a flexible tube with a camera into the esophagus, stomach, and duodenum to visualize the upper gastrointestinal tract.

While it is important to provide the client with information about the duration of the procedure, stating a specific time frame may not be accurate or helpful. The duration of an esophagogastroduodenoscopy can vary depending on factors such as the complexity of the procedure and the client's individual circumstances.

Having a full bladder is not necessary for an esophagogastroduodenoscopy procedure. This requirement may be relevant for other procedures, such as pelvic ultrasound, but it is not applicable in this case.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Correct Answer is B

Explanation

A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regimen. Which of the following instructions should the nurse include?

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?