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 The client is oriented times four, but is despondent and withdrawn.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.

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Correct Answer is B

Explanation

A. Measure urinary output.
Measuring urinary output is important for monitoring fluid balance but is not the most critical intervention for assessing left-sided heart failure specifically.
B. Auscultate all lung fields.
Auscultating lung fields is crucial for assessing signs of pulmonary edema, a key symptom of left-sided heart failure. It provides direct information about the severity of the condition and guides further management.
C. Check mental acuity.
Checking mental acuity can be useful but is not the most critical intervention for managing left-sided heart failure. It is less directly related to evaluating the severity of heart failure compared to lung auscultation.
D. Inspect for sacral edema.
Inspecting for sacral edema is more relevant for right-sided heart failure. For left-sided heart failure, the priority is evaluating pulmonary symptoms, not peripheral edema.

A. Notify the unit charge nurse of the finding. B. Administer humidified oxygen per nasal cannula. C. Ensure that the drainage device is compressed. D. Obtain a cup of ice chips for the client.

Correct Answer is A

Explanation

A. Hoarseness in the voice following a thyroidectomy can be a sign of vocal cord damage or laryngeal nerve injury, which are potentially serious complications. The appropriate action is to notify the unit charge nurse to escalate the finding for further assessment by a physician or advanced practice provider.
B. Administering humidified oxygen does not specifically address the issue of hoarseness. While humidified oxygen might be beneficial for general respiratory comfort, it is not a targeted intervention for potential vocal cord damage.
C. Ensuring that the drainage device is compressed is important for managing surgical wounds but does not address or diagnose vocal cord issues. Hoarseness after thyroid surgery is more indicative of a potential complication rather than a drainage issue.
D. Obtaining ice chips does not address the underlying cause of the hoarseness and may not provide significant relief. The priority is to identify potential complications rather than offering symptomatic relief.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

Correct Answer is B

Explanation

While caring for a client one day following a thyroidectomy, the practical nurse (PN) notes that the client's voice is hoarse. Which action should the PN take?

Correct Answer is A

Explanation

Exhibits What factors are important in determining level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?

The practical nurse (PN) is documenting the insertion of a urinary catheter for a female client with urinary retention. What information should the PN include during the electronic documentation of the procedure? Select all that apply.

A 2-month-old client is brought to the well-baby clinic. The parent is completing the consent forms for routine infant immunizations. Which immunization should the practical nurse (PN) prepare to administer?

The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location? (Select the correct location on the image)

The practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.

The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?