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Admission Assessment Day 1, 1000:

An older adult client was transferred to the ICU after they developed 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: 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. 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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Correct Answer is D

Explanation

Having the baby latch on to both the nipple and areola during breastfeeding is essential for effective milk transfer and optimal breastfeeding. The baby should take in a good portion of the areola along with the nipple to ensure a proper latch and a comfortable feeding experience for both the mother and the baby. This allows the baby to obtain enough milk and stimulates milk production in the mother.

Let's briefly discuss the other statements:

A- "My baby should breastfeed 5 to 10 minutes on each breast": The duration of breastfeeding can vary from baby to baby, but it is generally recommended to allow the baby to breastfeed until they are satisfied and have emptied one breast before switching to the other breast. This ensures that the baby receives both the foremilk and the hindmilk, which are important for adequate nutrition.

B- "I should not wake my baby during the night to breastfeed": In the early days after birth, it is important to establish frequent and regular breastfeeding to support milk production and ensure the baby receives enough nourishment. Newborns typically need to breastfeed at least 8 to 12 times in 24 hours, including during the night. If the baby is sleeping for a long period, it may be necessary to wake them for feeding to ensure proper nutrition and hydration.

C- "I should keep my baby on a strict feeding schedule": Breastfeeding should be based on the baby's cues and demand rather than a strict schedule. Newborns should be breastfed whenever they show hunger signs, such as rooting, sucking motions, or increased alertness. This helps establish a good milk supply and allows the baby to feed according to their individual needs.

A. Gently massage the eyelid to facilitate absorption of the medication. B. Wipe any excess medication from the inner canthus outward. C. Place an occlusive dressing on the affected eye to prevent the spread of infection. D. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days.

Correct Answer is B

Explanation

B. Wipe any excess medication from the inner canthus outward

Bacitracin ophthalmic ointment is an antibiotic medication commonly used to treat bacterial eye infections such as conjunctivitis.

Wiping any excess medication from the inner canthus outward, is important to prevent the accumulation of excessive ointment, which can cause discomfort and affect vision. Using a clean, sterile cotton ball or tissue, the nurse should gently wipe any excess ointment from the inner corner of the eye (inner canthus) and then move outward to remove the excess ointment.

Gently massaging the eyelid to facilitate absorption of the medication in (option A) is not recommended. It can potentially cause discomfort or further irritation to the affected eye, especially in a young child. The ointment will naturally spread across the eye as the child blinks.

Placing an occlusive dressing on the affected eye in (option C) is not necessary for the treatment of bacterial conjunctivitis. It may impede proper air circulation and potentially worsen the infection. It is important to promote hygiene and prevent the spread of infection by encouraging proper handwashing and avoiding touching or rubbing the affected eye.

Instructing the guardian to apply erythromycin ophthalmic ointment every morning for 14 days in (option D) is not appropriate in this case. Erythromycin is an alternative antibiotic commonly used for conjunctivitis, but since the child has been prescribed bacitracin ophthalmic ointment, the appropriate course of treatment would be to follow the prescribed medication as directed by the healthcare provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about breastfeeding with the mother of a full-term newbornwho is 5 days old. Which of the following statements by the mother indicates an understandingof the teaching?

Correct Answer is D

Explanation

A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenevermedication changes are prescribed by the client's provider. The nurse should identify that theclient is using which of the following defense mechanisms?

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client about advanced directives. Which of the following information should the nurse include?

A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?