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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

Montelukast is a medication commonly used for the maintenance treatment of asthma. It is not used for immediate relief of wheezing or acute symptoms. Instead, it is taken on a scheduled basis to help control and prevent asthma symptoms over time. The recommended dosing regimen for montelukast in children is once daily in the evening.

The statement about giving the medication every 2 hours, if the child is wheezing, is incorrect, as this medication is not meant to be used for immediate relief of symptoms. It is a preventive medication.

The statement about it taking 2 months of scheduled use before the medication is effective is incorrect. While it may take some time for the medication to reach its full effect, improvement in symptoms can often be seen within a few days to weeks of starting treatment.

The statement about stopping the medication if the child is taking a steroid is incorrect. Montelukast can be used in conjunction with other asthma medications, including steroids, as prescribed by the healthcare provider. It is important to follow the prescribed treatment plan and not discontinue any medication without consulting the healthcare provider.

A. Colostrum provides many important antibodies that the newborn lacks. B. Colostrum contains iron, which is important for a newborn's brain development. C. Colostrum provides vitamin K. which is an essential nutrient for newborns. D. Colostrum contains a natural diuretic that stimulates the newborn to void.

Correct Answer is A

Explanation

Colostrum provides many important antibodies that the newborn lacks.

Colostrum is the thick, yellowish fluid produced by the breasts during the early days after giving birth. It is rich in antibodies, immune factors, and other beneficial components that provide important protection and support for the newborn's health. Colostrum is often referred to as "liquid gold" due to its valuable properties. Antibodies present in colostrum help to strengthen the newborn's immune system and provide protection against various infections and diseases.

These antibodies are especially important during the first few days of life when the newborn's own immune system is still developing.

Option B is incorrect because colostrum does not contain a significant amount of iron. Iron is generally obtained from other sources, such as breast milk or iron-fortified formula, to support the newborn's brain development.

Option C is incorrect because although colostrum contains various essential nutrients, it does not provide a significant amount of vitamin K. Vitamin K is typically given to newborns as a separate supplement to prevent vitamin K deficiency bleeding.

Option D is incorrect because colostrum does not act as a diuretic. Its primary role is to provide the newborn with essential nutrients, antibodies, and immune factors to support their overall health and development.

In summary, colostrum is important for the newborn because it provides valuable antibodies that the newborn lacks, helping to strengthen their immune system and protect against infections and diseases.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. Why is colostrum so important for my baby? Which of the following responses should the nurse make?

Correct Answer is A

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?

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine?

A nurse is caring for a client who has a prescription for levothyroxine. Which of the following laboratory tests should the nurse monitor?

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?