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 D

Explanation

D. Severe obstructive sleep apnea poses a risk of respiratory compromise, particularly when compounded by the effects of opioid analgesics, which can depress respiratory drive. Applying the client's prescribed positive airway pressure (PAP) device, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), helps maintain airway patency and ensures adequate ventilation

A. It promotes better alignment of the airway, decreasing the likelihood of obstruction by the tongue or soft tissues. While this intervention is beneficial for managing OSA, it may not be the most critical intervention in this context.

B. Removing dentures or oral appliances may be necessary to prevent airway obstruction, especially during sleep when muscle tone is decreased. However, it is not the most critical intervention in this scenario

C. Securing side rails is important for client safety, especially in postoperative settings where clients may be at risk of falls. However, it does not directly address the client's obstructive sleep apnea or potential respiratory compromise from opioid administration.

A. Empty the sample into the 24 hour container. B. Start collecting the specimen with the next void. C. Begin the collection the next day. D. Observe the sample for sediment

Correct Answer is B

Explanation

A. Emptying the sample into the 24-hour container would mix the previously voided urine with the new collection, leading to inaccurate results.

B. The nurse should discard the urine that was collected earlier and start the collection process anew with the next void. This ensures that the entire 24-hour urine output is collected accurately.

C. The collection can be started immediately with the next void, even if it's a few hours after the original start time.

D. Observing the sample for sediment does not address the need for a complete 24-hour collection.

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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 nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is D

Explanation

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Correct Answer is B

Explanation

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