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During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

Instruct the client to report promptly to the practitioner any decreased redness, swelling, pain, or discharge from the incision or drain sites.

Emphasize the importance of adequate rest for healing and immune function.

Instruct the client to use pain medications as ordered and not to exceed the prescribed dose.

Teach the client to avoid using alcohol or other central narcotic analgesics.

Answer and Explanation

The Correct Answer is A

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. This includes instructing the client to report promptly to the practitioner any **increased** redness, swelling, pain, or discharge from the incision or drain sites. These symptoms may indicate an infection or other complication that requires medical attention. The other actions listed are correct and important for promoting healing and wellness after discharge.

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Correct Answer is C

Explanation

The priority nursing diagnosis for this client should be Risk for injury related to somnambulism. Somnambulism, also known as sleepwalking, can put the client at risk for injury as they may engage in activities while not fully conscious. The client's report of falling asleep while driving and almost being involved in an accident further highlights the potential risk for injury. It is important for the nurse to address this risk and develop a plan to ensure the client's safety.

A. Blood pressure: 120/80. B. Pain rating of 4 on a scale of 1 to 10. C. Pulse rate: 80. D. Respiratory rate: 8.

Correct Answer is D

Explanation

The nurse should immediately report a respiratory rate of 8 to the physician. A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A respiratory rate of 8 is considered abnormally low and can indicate respiratory depression, which can be a side eﬀect of pain medication delivered through an epidural catheter. It is important for the nurse to report this finding immediately so that appropriate interventions can be taken to ensure the safety of the client.

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During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Correct Answer is C

Explanation

The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

The nurse instructs the client on mind-body therapies. Which mind-body therapy is used when the client pictures themselves lying on a beach with the sounds of waves, the cries of seagulls, and the warmth of the sun during periods of stress?

A nurse is conducting a lung assessment on a client suspected of having pneumonia. Which finding should the nurse report to the physician immediately?

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.

The nurse is oﬀering free occult blood screenings at a community health fair. Which level of practice is the nurse providing?

Which is an example of a closed-ended question or statement?

A nurse is providing care for a client who has recently been diagnosed with type 1 diabetes mellitus. To focus on aﬀective learning with this client, the nurse should use which of the following interventions?