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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

D. To assess fever patterns accurately in a client with a fever of unknown origin, the nurse should measure the temperature at regular intervals. This helps in identifying trends and patterns in the fever, such as spikes at specific times of the day or consistent elevations. Regular temperature measurements provide valuable information for the healthcare team to diagnose and manage the underlying cause of the fever effectively.

A. Assessing for flushed, warm skin can be indicative of fever, due to vasodilation and skin flushing. While this assessment can provide subjective clues about the presence of fever, it does not provide comprehensive information about fever patterns over time.

B. Different sites may reflect variations in temperature due to local factors or differences in blood flow. However, while varying sites can contribute to a comprehensive assessment of body temperature, it does not specifically address the need to assess fever patterns over time.

C. While circadian rhythms can influence temperature variations, particularly in relation to sleep- wake cycles, documenting circadian rhythms alone does not provide specific information about fever patterns.

A. Erythema and serosanguineous exudate. B. Eschar and slough in the wound. C. Beefy red granulation tissue. D. A well approximated incision site.

Correct Answer is D

Explanation

A. Erythema (redness) and serosanguineous exudate (clear to blood-tinged fluid) are typical findings in the early stages of wound healing, especially within the first few days post-surgery. However, one week post-surgery, these signs should begin to decrease as the wound progresses through the inflammatory phase of healing.

B. Eschar (dry, black, or brown necrotic tissue) and slough (yellow or white soft tissue) are indicative of non-viable tissue and delayed wound healing.

C. Beefy red granulation tissue is a positive sign of healing. It indicates new tissue formation, which is essential for the healing process. Granulation tissue is typically moist, and its presence suggests that the wound is progressing well towards healing.

D.This indicates that the edges of the incision are properly closed and healing as expected.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is D

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

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?

The nurse is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

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.