Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Urinary output.

Serum electrolytes.

Peristomal skin integrity.

Skin turgor.

Answer and Explanation

The Correct Answer is B

A.   While monitoring urinary output is important, it is not the most critical assessment in this context.
B.   Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C.   Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D.   Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.

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Correct Answer is A

Explanation

A. A right foot that is pale with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, and requires immediate intervention to prevent tissue damage.
B. Circumferential edema of the right foot may be expected after a fracture and casting but does not indicate an immediate complication requiring intervention.
C. Reports of throbbing right leg pain are common after a fracture and casting and may be managed with appropriate pain medication but do not necessarily indicate an immediate complication.
D. An increased temperature to the lower extremity may be indicative of inflammation but does not necessarily require immediate intervention unless accompanied by other signs of infection or complications.

A. Measure capillary refill time. B. Palpate for dependent edema. C. Determine degree of skin elasticity. D. Note hand and forearm strength.

Correct Answer is D

Explanation

A. Capillary refill time assessment is more relevant for circulatory status and would not directly address the client's difficulty with crutch management.
B. Palpating for dependent edema would not provide information directly related to the client's ability to use crutches.

C. Assessing skin elasticity is not directly related to the client's ability to manage crutches.
D. Strength in the hands and forearms is essential for proper crutch use, as these muscles bear much of the weight while ambulating with crutches.

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Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

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Naxlex Comprehensive Predictor Exams

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

Correct Answer is D

Explanation

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?