Exhibits

Review H and P and nurse's note.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

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Correct Answer is A

Explanation

A. Paper masks and gowns used for isolation precautions should be placed in a designated biohazard bag before removal from the room. These items are considered contaminated and must be disposed of according to infection control protocols.
B. A sputum specimen should be placed in a sealed, labeled container before being transported to the lab, not in a biohazard bag for disposal.
C. The nurse's stethoscope should be disinfected but does not need to be disposed of unless it is single-use.
D. Bed linens are typically placed in a laundry bag specifically designated for contaminated linens, not in a biohazard bag.

A. Hand tremors. B. Shuffling gait. C. Urinary incontinence. D. Diminished visual acuity. E. Syncope when bending.

Correct Answer is ["A","B","D"]

Explanation

A. Hand tremors can impair the client’s ability to safely and effectively perform fine motor tasks, such as toenail care, making it necessary to assign a UAP for this task.
B. A shuffling gait suggests a mobility issue, which may make it difficult for the client to safely bend over and care for their feet, increasing the risk of falls or improper foot care.
C. Urinary incontinence does not directly impact the client’s ability to perform foot care and is not a reason to assign a UAP for this task.
D. Diminished visual acuity affects the client’s ability to see clearly, which is crucial when performing tasks like toenail care to avoid injury.
E. Syncope when bending indicates a risk of fainting, but it is not specifically related to the need for routine foot care by a UAP.

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Naxlex Comprehensive Predictor Exams

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Correct Answer is A

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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