Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["C"]

Explanation

A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.

B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.

C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.

D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.

A. Provide a stimulating environment for the client B. Use confrontation to manage the client's behavior C. Limit the number of choices for the client D. Use written signs to assist the client with locating the bathroom

Correct Answer is ["A","C","D"]

Explanation

Correct:

A. Creating a stimulating environment helps engage the client and can reduce restlessness and agitation. This can include activities, social interactions, and sensory stimulation tailored to the individual's preferences.

C. Clients with Alzheimer's disease may become overwhelmed and have difficulty making decisions when presented with too many options. By limiting choices, caregivers can help reduce confusion and frustration for the client.

D. Clients with Alzheimer's disease may experience memory impairment and difficulty with orientation. Using written signs can help them navigate their surroundings and locate essential areas, such as the bathroom. Clear and simple signs can be helpful for maintaining independence and minimizing confusion.

incorrect:

B. Confrontation, which involves challenging or arguing with the client, can escalate agitation and distress. Instead, caregivers should use techniques such as redirection, validation, and providing a calm and supportive environment to manage challenging behaviors associated with Alzheimer's disease.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is ["C"]

Explanation

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

Correct Answer is ["A","C","D"]

Explanation

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 charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

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 reinforcing teaching about foot care with a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

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?