Patient Data

Exhibits

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

Based on the client's history, physical and laboratory findings, the priority need will be to treat
dropdown
, in addition, the client will need interventions to manage complications, especially
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"A"}

Rationale for correct choices:

• Infection: The client presents with redness, warmth, swelling, and pain in the left lower leg, accompanied by a small cut and a history of type 2 diabetes. These findings, along with elevated temperature and glucose, indicate a bacterial skin infection requiring prompt treatment with antibiotics to prevent progression.

• Sepsis: Older adults with diabetes and chronic comorbidities are at high risk for systemic infection. The client’s generalized muscle aches, fever, and elevated glucose may indicate early systemic involvement. Interventions to prevent sepsis, such as timely IV antibiotics, monitoring vital signs, and laboratory markers (e.g., WBC, lactate), are crucial to reduce life-threatening complications.

Rationale for incorrect choices:

• Congestive heart failure: While the client has a history of heart failure, the acute presentation of erythema, warmth, and localized swelling suggests infection rather than fluid overload as the priority concern. CHF management is important but secondary in this scenario.

• Kidney disease: Stage 3a chronic kidney disease is a chronic condition and does not explain the acute signs of infection. Monitoring kidney function is important for medication dosing, but it is not the immediate priority.

• Hyperglycemia: The client’s blood glucose is elevated at 252 mg/dL, likely worsened by stress and infection. Hyperglycemia requires monitoring and management, but the underlying infection poses a more immediate threat to health.

• Deep vein thrombosis: DVT can cause leg swelling and pain, but the presence of erythema, warmth, and a break in the skin indicates cellulitis rather than thrombus formation. DVT prevention may be part of ongoing care but is not the priority in this acute presentation.

• Peripheral neuropathy: The client has baseline neuropathy contributing to bilateral leg discomfort, but it does not explain the acute swelling, redness, and warmth. Pain management may be necessary, but infection treatment is urgent.

• Edema: Edema is a symptom present in several chronic conditions, including CHF and PVD, but in this case, localized edema is part of the infection process. Addressing the infection takes priority over general edema management.

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Correct Answer is D

Explanation

A.Monitoring an intravenous infusion rate involves the assessment of fluid delivery and the mechanical function of medical equipment. This task requires specialized knowledge of pharmacology and potential complications like infiltration or circulatory overload, which are outside the UAP's training. Only a licensed nurse can legally monitor and validate the accuracy of an IV pump schedule. Delegating this to unlicensed staff poses a significant risk for medication errors and fluid imbalances.

B. Titrate oxygen to the prescribed parameters: Adjusting oxygen requires clinical judgment and assessment of respiratory status, including oxygen saturation and signs of hypoxia. This is a nursing responsibility and cannot be delegated to a UAP.

C. Insert a urinary catheter for an uncomplicated client: Catheter insertion is a sterile procedure that requires nursing knowledge and skill. Delegation to a UAP is not permitted due to the risk of infection and need for proper technique.

D. Procuring blood or platelet products from the blood bank is a standard administrative task that falls within the UAP scope of practice. This activity does not require clinical judgment, nursing assessment, or the performance of a sterile procedure. The nurse remains responsible for the final verification of the blood product at the bedside, but the physical transport is a safe delegation. It allows the nurse to remain on the unit for higher-priority clinical duties.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Explanation

Rationale for correct choices:

• Cellulitis: The client presents with redness, warmth, swelling, and pain in the left lower leg, along with a small preceding cut. These findings are characteristic of cellulitis, a bacterial infection of the dermis and subcutaneous tissue, often following a breach in the skin barrier.

• Break in skin: The small cut noted above the lateral ankle provides an entry point for bacteria, explaining the localized infection. A break in skin is a common precursor to cellulitis, particularly in clients with diabetes or vascular compromise.

• Left lower leg erythema: Erythema indicates inflammation and infection, which are hallmark signs of cellulitis. The presence of erythema, along with swelling and warmth, supports the clinical diagnosis of a bacterial skin infection.

Rationale for incorrect choices:

• Left lower leg erythema (as a diagnosis option): Erythema alone describes a symptom rather than a medical diagnosis. While present, it does not capture the underlying bacterial infection requiring treatment.

• Break in skin (as a diagnosis option): A break in the skin is a risk factor or contributing event, not a formal diagnosis. It explains how infection occurred but does not replace the clinical diagnosis of cellulitis.

• Cool, pale left leg: This finding is more indicative of arterial insufficiency or ischemia rather than infection. The client’s affected leg is warm and erythematous, which contrasts with cool, pale tissue.

• Intact skin: Intact skin would not allow bacterial entry and does not explain the localized infection. The client has a visible small cut that preceded the erythema.

• Dry scaly skin: While common in peripheral vascular disease or chronic dermatologic conditions, dry scaly skin does not explain the acute signs of infection seen in this client.

View Question and Answer

Patient Data

Exhibits

For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

View Question and Answer

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Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Explanation

An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

Patient Data Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.