Patient Data

Exhibits

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Instruct incentive spirometry use every hour.

Use petroleum based lotion on skin.

Administer antibiotics.

Suggest that client ambulate often.

Encourage consumption of protein and vitamin C.

Apply thromboembolism deterrent stockings (TED).

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Abdominal cramping: Mild to moderate abdominal cramping is a common symptom of acute gastritis and may not indicate a complication. While it should be monitored, it is not typically an emergency sign.

B. Bloody emesis: Vomiting blood may indicate gastrointestinal bleeding, a serious complication of acute gastritis. Immediate reporting is essential to prevent significant blood loss and allow prompt medical intervention.

C. Low grade fever: A mild fever can accompany gastritis due to inflammation or infection but is not usually life-threatening. It should be monitored but does not require urgent reporting unless it worsens.

D. Bruising of the skin: Easy bruising is not a typical manifestation of gastritis and is not directly related to acute gastrointestinal complications. It may suggest another underlying condition but is not the priority concern for this client.

A. Ask the chaplain to discuss death issues with the client. B. Notify the family that treatments have been discontinued. C. Request a consultation with the hospital social worker. D. Arrange a meeting with the family, healthcare provider, and client.

Correct Answer is D

Explanation

A. Ask the chaplain to discuss death issues with the client: While spiritual support may be helpful, this does not address the client’s expressed conflict about continuing treatment to satisfy his family’s wishes.

B. Notify the family that treatments have been discontinued: The nurse cannot make the decision to discontinue treatments without the client’s and healthcare provider’s input. This would be outside the nurse’s scope of authority.

C. Request a consultation with the hospital social worker: Although a social worker can help with emotional support and end-of-life planning, the immediate concern is facilitating open communication between the client, family, and healthcare team about the client’s wishes.

D. Arrange a meeting with the family, healthcare provider, and client: This action supports the client’s autonomy and ensures his wishes are heard. It also promotes collaborative decision-making about continuing or stopping treatment, aligning care with the client’s goals and values.

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Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is B

Explanation

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client verbalizes that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

Correct Answer is D

Explanation

Which oral medication can the nurse safely cut in half?

Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions?

Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

Patient Data

Exhibits

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.