The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?

Request to have the client lie as still as possible for the assessment.

Ask the client how often episodes of sundowning are experienced.

Question the client about the frequency of falls in recent months.

Assist the client with clarifying values about end-of-life care

Answer and Explanation

The Correct Answer is C

A)   Incorrect - Requesting the client to lie still may be relevant for certain assessments, but it is not specific to the situation described in the question.
B)   Incorrect - Inquiring about episodes of sundowning is more relevant for clients with cognitive impairment and is not directly related to the client's weight loss and decreased energy and appetite.
C)   Correct - Questioning the client about the frequency of falls is important, as falls can contribute to weight loss, decreased energy, and appetite changes in older adults.
D)   Incorrect - Assisting the client with clarifying values about end-of-life care is a valuable nursing intervention but is not the priority in this assessment scenario.

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Correct Answer is A

Explanation

Demonstrate how to administer medication via a feeding tube.The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, ﬂushing the tube with water, instilling the medication, ﬂushing again, and resuming the feeding.

The other options are not correct because:

Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
Oﬀering to assist in calculating the rate of ﬂow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.

A. Palpate the rate and volume of the pulse. B. Check fingernails for the presence of clubbing. C. Measure body weight at the same time daily. D. Observe the color and amount of urine. E. Compare muscle strength of both arms.

Correct Answer is ["A","C","D"]

Explanation

The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of ﬂuid volume excess. These actions can help detect changes in the cardiovascular, renal, and ﬂuid balance systems that may indicate ﬂuid overloads, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.

The other options are not correct because:

B. Checking fingernails for the presence of clubbing is not relevant for assessing ﬂuid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.

E. Comparing muscle strength of both arms is not relevant for assessing ﬂuid volume excess, as muscle weakness is not a specific sign of ﬂuid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.

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The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

Correct Answer is A

Explanation

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?

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The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

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