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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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Free Nursing Study Resources

Correct Answer is ["0.25"]

Explanation

To calculate the amount of haloperidol oral concentrate the nurse should administer, we can use the following equation:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

In this case, the dose is 0.5 mg and the concentration of the haloperidol oral concentrate is 2 mg/mL.

Volume (mL) = 0.5 mg / 2 mg/mL

Volume (mL) = 0.25 mL

A. Determine the circulation status of the affected extremities every 2 hr. B. Evaluate the need for the client to remain in mitten restraints. C. Instruct the client's family about the purpose of mitten restraints. D. Assist the client with range-of-motion exercises of the hands.

Correct Answer is D

Explanation

Range-of-motion exercises are within the scope of practice for an AP and do not require specialized nursing knowledge or assessment skills. The AP can assist the client in performing these exercises to promote circulation, maintain joint mobility, and prevent complications associated with immobilization.

Determining the circulation status of the affected extremities, evaluating the need for restraints, and providing education to the client's family about the purpose of restraints require nursing assessment, critical thinking, and communication skills. These tasks should be performed by a licensed nurse who can make clinical judgments and ensure the safety and well-being of the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["0.25"]

Explanation

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?

Correct Answer is D

Explanation

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