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

Explanation

A. When identifying goals to be included in a client's plan of care, the nurse should compare the client's manifestations (signs and symptoms) with the defining criteria of related nursing problems or diagnoses. This involves assessing the client's current health status, identifying specific problems or areas of concern, and determining desired outcomes or goals for improvement.

B. Reviewing the priority nursing problems already included in the plan of care helps the nurse understand the client's current status and ongoing care needs. However, this may leave out other client needs not stated as priority

C. While listing immediate nursing actions is important for addressing urgent care needs, it does not directly address the process of identifying goals for the client's plan of care.

D. Ensuring that prescribed treatments have been initiated is an important aspect of client care, but it pertains more to implementation rather than goal identification.

A. Remove tubing while eating. B. Keep the tank in a cool place. C. Avoid direct skin contact. D. Place a pad around the tank.

Correct Answer is C

Explanation

C. Oxygen is a highly combustible gas, and direct contact with oil or grease can increase the risk of fire. Therefore, avoiding direct skin contact helps minimize this risk.

A. Clients should not remove the oxygen tubing while eating. It’s essential to continue oxygen

therapy during meals to maintain adequate oxygen levels.

B. Oxygen tanks should be stored in a well-ventilated area but not in a confined space. Avoid extreme temperatures (both hot and cold) and direct sunlight.

D. Although it’s essential to secure oxygen tanks to prevent tipping, placing a pad around the

tank is not a standard safety practice.

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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

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Correct Answer is B

Explanation

The nurse is providing safety instructions to a client who is being discharged home with oxygen therapy. Which information provided by the client indicates understanding?

Correct Answer is C

Explanation

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