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 B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

A. Skin pale and diaphoretic B. Respiratory rate 36 breaths/minute C. Blood pressure 140/86 mm Hg D. Temperature 101.1° F (38.4" C) orally E. Bilateral basilar crackles F. Bilateral radial pulses bounding G. Heart rate 117 beats/minute and irregular H. Oxygen saturation 98% on room air

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

Explanation

A. Skin pale and diaphoretic: These can be signs of dehydration, infection, or other conditions.
B. Respiratory rate 36 breaths/minute - This is elevated, especially for a child, indicating potential respiratory distress or infection, particularly given the patient's history and current fever.
C. Blood pressure 140/86 mm Hg - This is high for a 7-year-old and could indicate fluid overload or other complications related to his chronic kidney disease.
D. Temperature 101.1° F (38.4° C) orally - Continued fever despite antipyretic treatment suggests ongoing infection or inflammation needing further evaluation.
E. Bilateral basilar crackles - This could suggest fluid in the lungs (pulmonary edema), which is critical given the patient's possible fluid overload and high blood pressure.
F. Bilateral bounding radial pulses is not necessarily a cause of concern in the above case.

G. Heart rate 117 beats/minute and irregular - An elevated and irregular heart rate in a child is concerning and could indicate cardiovascular stress or electrolyte imbalances, which need addressing given his elevated potassium levels.
H. Oxygen saturation 98% on room air: Normal oxygen saturation suggests adequate gas exchange.

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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

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

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

Explanation

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