An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

24-hour medication history.

Amount of serous drainage from the wound.

Urinary output for past six hours.

White blood cell count.

Answer and Explanation

The Correct Answer is D

A. While the medication history can be relevant, it is not the most immediate assessment needed to address the confusion and possible infection.

B. The amount of serous drainage is important for wound assessment but does not directly address the cause of confusion.

C. Urinary output is useful for evaluating kidney function but may not be directly related to the client’s confusion and wound.

D. The white blood cell count is crucial for identifying an infection or inflammatory response, which could be related to both the confusion and the wound.

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Correct Answer is B

Explanation

A. Grilled chicken over romaine lettuce provides protein but lacks sufficient calcium and vitamin D, which are essential for bone health.

B. Salmon patties and collard greens are rich in calcium and vitamin D, which are crucial for osteoporosis prevention. Salmon contains vitamin D, and collard greens are high in calcium.

C. Tuna and sautéed spinach provide protein and some vitamins, but they may not be as rich in calcium and vitamin D compared to salmon and collard greens.

D. Beef steaks and asparagus offer protein and some nutrients but lack the high levels of calcium and vitamin D needed for bone health.

A. Maintain strict intake and output. B. Assess warmth of extremities. C. Monitor blood glucose level. D. Keep head of bed raised 45 degrees.

Correct Answer is A

Explanation

A. Maintaining strict intake and output is crucial in managing septic shock as it helps to monitor fluid balance, which is essential for managing hypovolemia and ensuring adequate perfusion.

B. While assessing warmth of extremities is important, it is not as directly related to the immediate management of septic shock as monitoring intake and output.

C. Monitoring blood glucose levels is important, especially in septic patients, but it is not the primary focus in the initial management of septic shock.

D. Keeping the head of the bed raised 45 degrees can help with breathing but is not the most critical intervention in the immediate management of septic shock.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a class about osteoporosis prevention. Which meal should the nurse recommend to the class?

Correct Answer is B

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

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