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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Valid and reliable health information sources should provide references or citations to support the information they present. This demonstrates that the information is based on evidence and has been reviewed by experts in the field. It allows readers to verify the accuracy and reliability of the information by referring to the cited sources.

The author's name listed without credentials does not provide information about the author's expertise or qualifications. It is important to assess the author's credentials and expertise to determine their credibility.

The website URL being listed as .com does not provide information about the accuracy or reliability of the content. Different types of websites, such as .org or .gov, can also contain credible health information.

The website being last updated 3 years ago raises concerns about the currency and relevance of the information. Health information can quickly evolve, and it is important to access up-to-date resources.

A. Avoid quoting client comments when documenting. B. Limit documentation to subjective information. C. Document giving a dose of pain medication just prior to administration. D. Document information telephoned in by a nurse who left the unit for the day.

Correct Answer is A

Explanation

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information?

Correct Answer is B

Explanation

A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?