An older adult client is admitted to the hospital from a skilled care facility with dehydration and malnourishment. The client is oriented times four, but is despondent and withdrawn. The practical nurse (PN) observes that the client has multiple bruises on both arms and has poor hygiene. Which action should the PN implement first?

Document suspected abuse using the physical findings as supporting evidence.

Establish trust with the client to ensure basic needs and open communications are met.

Medicate the client as prescribed to ensure adequate rest and interventional therapies.

Contact social services to investigate the personnel at the skilled care facility.

Answer and Explanation

The Correct Answer is B

A. While documentation is essential, establishing a trusting relationship with the client is a more immediate priority to address their basic needs and gather information.
B. Establishing trust with the client is crucial to ensure their basic needs are met and to create an environment where the client feels safe to communicate openly. This foundational step is necessary before other interventions can be effectively implemented.
C. Medicating the client as prescribed is important for their overall care but does not address the immediate need to build trust and assess their situation comprehensively.
D. Contacting social services is a necessary step if abuse is suspected, but it should follow the initial assessment and establishment of trust with the client to gather accurate information.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","D","E","F"]

Explanation

A. A warning about potential charges for child neglect
This is not appropriate in a pre-discharge education context. The focus should be on providing support and education to prevent future incidents and to help the parents understand the importance of supervision and safety.
B. Information about pool safety
Providing information about pool safety is essential to prevent future drowning incidents. Parents should be educated on supervision, barriers, and emergency response measures like CPR. This helps ensure the child's safety and reduces the risk of similar accidents.
C. Instructions on how to access long-term home care
Long-term home care instructions are unnecessary unless the child has specific ongoing medical needs resulting from the submersion. Since the child is showing only minor signs of impact, this education is not relevant.
D. When to follow up with the child's pediatrician
Clear instructions on when to follow up with the pediatrician ensure ongoing monitoring for any delayed effects of the submersion injury. This follow-up helps address any emerging health concerns and reassures the parents about their child's recovery.
E. Assessment of the parent's coping skills
Assessing the parents' coping skills is important to understand their emotional and psychological state post-incident. This can help identify any need for further support or counseling, ensuring the family is equipped to handle the situation.
F. Contact information for community resources
Providing contact information for community resources offers additional support to the parents, such as access to counseling, parenting classes, or safety courses. This reinforces the safety education provided and ensures the parents have resources to turn to if needed

A. Place a biohazard bag over the basin and seal the bag securely for transport to the lab. B. Assist the client in obtaining another specimen coughed directly into a sterile cup. C. Use a wooden applicator to place the sputum specimen in a sterile container. D. Apply gloves and place the tissue and specimen in a container for transport to the lab.

Correct Answer is B

Explanation

A. Placing a biohazard bag over the basin and sealing it is not appropriate because the specimen should have been collected directly into a sterile container, and the specimen's current state in a non-sterile basin is not acceptable for lab analysis.
B. Assisting the client in obtaining another specimen is necessary to avoid cross contamination.
C. Using a wooden applicator to place the sputum specimen in a sterile container is the incorrect as it breaches sterility.
D. Applying gloves and placing the tissue and specimen in a container is incorrect as the specimen must be in a sterile container from the start. Using a non-sterile basin means the specimen might be contaminated.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","E","F"]

Explanation

Correct Answer is B

Explanation

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in the high position. Which action should the PN take?

A client receives ondansetron prior to a chemotherapy treatment. How should the practical nurse evaluate the effectiveness of the medication?

A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action?

Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the PN monitor? Select all that apply.

An older adult client who was admitted to a long-term care facility yesterday is confused about what day of the week it is. The history does not indicate that the client was confused prior to admission. Which action should the practical nurse (PN) take?