The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Fluid volume deficit.

Caregiver role strain.

Bowel incontinence.

Impaired bed mobility.

Answer and Explanation

The Correct Answer is A

A.   Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B.   While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C.   This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D.   Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.

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Correct Answer is ["22"]

Explanation

To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.

A. Find outlets for more social interaction. B. Think about reasons the episodes occur. C. Practice using muscle relaxation techniques. D. Center attention on positive upbeat music.

Correct Answer is C

Explanation

A. Social interaction can help, but it is not the most effective immediate strategy for managing anxiety.
B. Reflecting on the reasons for anxiety is useful for long-term management but not for immediate relief.
C. Muscle relaxation techniques are an effective and immediate method for reducing anxiety symptoms.
D. Listening to music can help but is less effective than targeted relaxation techniques.

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The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

Correct Answer is ["22"]

Explanation

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

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