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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Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is choice c. Place padding around the cannula tubing.

Choice A rationale:

Discontinuing the use of the nasal cannula is not appropriate because the client still needs supplemental oxygen to maintain adequate oxygen saturation levels.

Choice B rationale:

Applying lubricant to the cannula tubing might help reduce friction but does not address the pressure that is causing the red mark.

Choice C rationale:

Placing padding around the cannula tubing helps to alleviate the pressure on the skin, which can prevent further irritation and allow the red mark to heal.

Choice D rationale:

Decreasing the flow rate to 1 L/minute could compromise the client’s oxygenation status, as the current flow rate is necessary to maintain an oxygen saturation level of 94%.

A. The medication is in short supply at the local pharmacy. B. The antibiotic has a limited shelf life after reconstitution. C. The healthcare provider should be notified of the discrepancy. D. The instructions may change over the course of therapy.

Correct Answer is B

Explanation

Choice A reason: While medication shortages can occur, this is not the typical reason for delivering a partial supply of medication for home health care.

Choice B reason: Daptomycin is an antibiotic that has a limited shelf life after it is mixed or reconstituted. This is why pharmacies often deliver only a portion of the doses to ensure the medication remains effective.

Choice C reason: Notifying the healthcare provider is necessary if there is a discrepancy in medication delivery that cannot be explained by standard pharmacy practices.

Choice D reason: Although instructions for medication administration may change, this is not the usual reason for a pharmacy to deliver a partial supply of medication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

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)?

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?