An older adult client who cares for her husband at home has just learned that she needs to have knee replacement surgery. She tells the nurse she is concerned about her inability to provide care to her husband while she recovers from surgery and attends physical therapy. She has a friend who can drive her to and from her appointments once she is discharged, but cannot provide the care her husband needs. How should the nurse respond to the client?

Tell her to consider hiring a private nurse during the postoperative convalescence.

Suggest contacting social services to help find a respite care facility for her husband.

Advise to have a case management evaluation of the client's home environment.

Recommend that the client's family return to the area to help provide assistance.

Answer and Explanation

The Correct Answer is B

A. Hiring a private nurse may be an option but is not the most immediate or practical solution given the client's current resources and concerns.

B. Suggesting contacting social services to find respite care is a practical and immediate solution to ensure her husband’s care while the client recovers.

C. A case management evaluation is helpful but may not address the immediate need for respite care during the client's recovery period.

D. Recommending that the family return might not be feasible or immediate, and respite care can provide the necessary support during recovery.

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Correct Answer is A

Explanation

A. Infusing normal saline intravenously is crucial as the infant shows signs of dehydration (weak cry, no tears), and intravenous fluids are necessary to restore hydration and electrolyte balance.

B. Applying an external cooling blanket may be necessary to manage fever but does not address the dehydration issue.

C. Providing an electrolyte solution is helpful, but given the infant’s refusal to drink, IV fluids are more immediate and effective.

D. Administering an antipyretic rectally might help manage fever but does not address the dehydration or fluid needs.

A. Apply heat to the infiltrated site. B. Document a delay in the administration of the antibiotic. C. Start a new IV at a different site to administer the antibiotic. D. Remove the infiltrated IV catheter.

Correct Answer is D

Explanation

A. Applying heat may be indicated later, but the first action should be to address the infiltration.

B. Documenting the delay is important but not the immediate priority.

C. Starting a new IV site is necessary for continued medication administration but should be done after addressing the infiltration.

D. Removing the infiltrated IV catheter is the first priority to prevent further tissue damage and start appropriate treatment for infiltration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Correct Answer is D

Explanation

While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

The nurse is assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client reports the left knee is swollen and extremely painful to touch. Which instruction should the nurse include in the discharge teaching?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?