The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

Bowel incontinence.

Impaired bed mobility.

Caregiver role strain.

Fluid volume deficit.

Answer and Explanation

The Correct Answer is D

D. Addressing fluid volume deficit promptly is essential to prevent complications such as hypovolemic shock and renal dysfunction.

A. Bowel incontinence, especially in a client with celiac disease experiencing diarrhea, can lead to skin breakdown, discomfort, and embarrassment. However, it may not be the highest priority if the client's safety and physiological needs are not compromised.

B. Impaired bed mobility after knee replacement surgery can impact the client's recovery, comfort, and risk of complications such as deep vein thrombosis (DVT). However, if the client's condition allows for safe positioning and mobility within bed, this problem may not be the highest priority compared to more immediate concerns.

C. Caregiver role strain is a valid concern, especially if the primary caregiver is experiencing difficulty managing the client's needs. However, the priority is typically focused on addressing the client's immediate physiological needs before addressing caregiver concerns.

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Correct Answer is ["B","C","D","E"]

Explanation

B. Hospice services can be initiated while the client is still in the hospital. Hospice teams can work alongside the hospital staff to provide care and support to the client and family during the transition to hospice care.
C. Hospice care emphasizes the involvement of family members in the care of the patient. The hospice team works with the patient and family to develop a personalized plan of care that addresses the physical, emotional, and spiritual needs of the patient and family members.
D. Hospice care focuses on providing comfort, maintaining dignity, and offering emotional support to patients with terminal illnesses and their families. The goal is to enhance quality of life and ensure that the patient's wishes and preferences are respected throughout the end-of- life process.
E. Hospice care can be provided in various settings, including the patient's own home, assisted living facilities, nursing homes, or inpatient hospice units. The option to receive care in the comfort of home is often preferred by many patients and families as it allows them to remain in familiar surroundings surrounded by loved ones.

A. Perform tracheostomy care, change coccyx dressing, restart the IV line. B. Change coccyx dressing, restart the IV line, perform tracheostomy care. C. Restart the IV line, perform tracheostomy care, change coccyx dressing. D. Change coccyx dressing, perform tracheostomy care, restart the IV line.

Correct Answer is C

Explanation

Restarting the IV line first ensures that the client has immediate access to intravenous fluids and medications, which is critical for maintaining hydration and treatment continuity. This is especially important if the client is receiving antibiotics or other medications that need to be administered continuously or urgently.

Following the IV line, performing tracheostomy care ensures that the airway is maintained and free from obstructions. This is essential, especially in clients with compromised respiratory function. By addressing the airway next, the nurse ensures that the client can breathe effectively and is stable.

Changing the coccyx dressing is important for wound management, especially with an infected wound. Performing this last minimizes the risk of contaminating the sterile field or the dressing while the nurse is managing other tasks. This also reduces the number of times the nurse enters and exits the room, adhering to contact isolation protocols.

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The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

Correct Answer is C

Explanation

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