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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 C

Explanation

Nausea and vomiting are common side effects of doxycycline, an antibiotic commonly used to treat chlamydial infections. Taking the medication with food or a snack can help alleviate these side effects. The recommendation to take the medication with crackers provides a light source of carbohydrates that can help settle the stomach and reduce nausea.

It is generally not recommended to take doxycycline with calcium-rich foods or beverages, as they can interfere with the absorption of the medication. Calcium can form complexes with doxycycline, reducing its effectiveness. Therefore, it is best to avoid calcium-rich foods and beverages, including calcium-fortified orange juice, when taking doxycycline.

Similar to calcium-rich foods, antacids can also interfere with the absorption of doxycycline. Antacids contain aluminum, magnesium, or calcium, which can bind to doxycycline and reduce its effectiveness. Therefore, it is generally recommended to avoid taking doxycycline with antacids.

While it is important to remain upright for a short period after taking some medications to prevent reflux or aspiration, this recommendation may not specifically address the client's nausea and vomiting. Taking the medication with food, such as crackers, may be more effective in alleviating the symptoms.

A. A social worker who is a. assigned to an involuntarily committed school-age client B. A client's employer who is concerned about safety due to substance use C. A nurse from another unit after a client commits suicide D. A client's partner after the client reports intimate partner abuse

Correct Answer is A

Explanation

Correct answer: A

Option A is correct.In this scenario, the social worker is likely involved in the client's care plan and needs the medical information to provide appropriate support services.Involuntary commitment: In cases of involuntary commitment, there might be a court order allowing for information sharing to ensure the client's well-being..

Option B is incorrect because sharing client information with a client's employer is generally not appropriate without the client's explicit consent. Confidentiality must be maintained, and any concerns about safety due to substance use should be discussed with the client and appropriate healthcare professionals.

Option C is incorrect.Sharing information with a nurse from another unit after a client commits suicide is generally not appropriate unless: there is a specific reason for sharing, such as identifying potential risks to other clients, the minimum amount of information necessary is shared and the sharing complies with HIPAA (Health Insurance Portability and Accountability Act) regulations.

Option D is incorrect because sharing client information with a client's partner after the client reports intimate partner abuse could potentially compromise the client's safety. It is crucial to follow specific protocols and laws related to reporting abuse while ensuring the client's confidentiality and well-being.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?

Correct Answer is C

Explanation

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

Correct Answer is A

Explanation

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider?

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?

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

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

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?