Patient Data

Exhibits

The nurse reviews the client’s data.

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 []

Choice A reason:

There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.

Choice B reason:

The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.

Choice C reason:

There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.

Choice D reason:

Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.

Choice E reason:

An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.

Condition F reason:

The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.

Condition G reason:

There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:

Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.

Condition I reason:

There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.

Parameter J reason:

Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.

Parameter K reason:

While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.

Parameter L reason:

Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.

Parameter M reason:

Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.

Parameter N reason:

Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.

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Correct Answer is D

Explanation

Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.

A. C-reactive protein level B. Serum potassium and sodium levels C. Neutrophil count D. Platelet count

Correct Answer is A

Explanation

Choice A reason: An increased boundary of the wound suggests possible infection or inflammation. C-reactive protein (CRP) is an acute-phase reactant produced by the liver in response to inflammation. A CRP test can help assess the severity of inflammation or infection. The normal range for CRP is generally below 10 mg/L.

Choice B reason: While serum potassium and sodium levels are important electrolytes to monitor, they are not directly related to wound assessment or infection. Normal ranges for potassium are 3.6 to 5.2 mmol/L, and for sodium, 135 to 145 mEq/L.

Choice C reason: Neutrophils are white blood cells that respond to infection. While an elevated neutrophil count can indicate infection, it is not as specific as CRP for inflammation. The normal range for neutrophils is 2,500 to 6,000 cells/mcL.

Choice D reason: Platelets are involved in clotting and would not necessarily change due to wound infection or inflammation. The normal platelet count range is 150,000 to 450,000 platelets/mcL.

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Naxlex Comprehensive Predictor Exams

When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

Correct Answer is D

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer is A

Explanation

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A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

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