The palliative care nurse is admitting a client who has metastatic bone cancer and is unable to eat or drink without immediate nausea and vomiting. The client is complaining of pain at 9 on a 0 to 10 pain scale, and the vital signs are: heart rate 99 beats/minute, respirations 38 breaths/minute, oxygen saturation 95%, and blood pressure 110/80 mm Hg. Which Intervention should the nurse implement?

Initiate infusion for an IV fluid bolus.

Administer an IV antiemetic.

Medicate with PRN IV narcotic.

Discourage straining on stool.

Answer and Explanation

The Correct Answer is C

A.   While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B.   Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C.   The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D.   This is not relevant to the client's current symptoms of severe pain and nausea.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. This instruction is not recommended because adding the second portion of the feeding before the syringe is empty can lead to inconsistent feeding rates and potential complications, such as overloading the stomach with too much formula at once.
B. Flushing the GT with water between portions of feeding is a good practice to prevent clogging and to ensure that all formula is delivered. However, 25 mL of water is generally not enough; standard practice typically involves using 30 to 60 mL of water for effective flushing. This option is close but not as specific as the recommended volume.
C. Raising the syringe barrel can increase the flow rate of the feeding, but this approach should be used with caution. Rapid flow can cause gastrointestinal discomfort or cramping. The primary focus should be on ensuring proper flushing and administration rather than manipulating the flow rate in this way.
D. This option is the best practice because flushing the GT with 50 mL of water between portions of the feeding helps to clear any remaining formula from the tube and prevents clogging. Proper flushing also helps ensure that the entire dose of formula is delivered and maintains tube patency.

A. Receiving immune suppressant therapy for cancer. B. Has hyperemia at the site of an acute local infection. C. Lost ten pounds adhering to a low carbohydrate diet. D. Recently received a series of adult immunizations.

Correct Answer is A

Explanation

A. Clients receiving immune suppressant therapy, such as those undergoing treatment for cancer, are at a significantly increased risk for healthcare-associated infections. Immune suppressants weaken the body's ability to mount an effective immune response, making individuals more susceptible to infections.
B. Hyperemia, or increased blood flow to a particular area, can be a sign of an acute local infection. While it indicates the presence of infection, the hyperemia itself does not increase the risk of developing a new or additional healthcare-associated infection.
C. Weight loss, especially if associated with dietary changes, may affect overall health and nutritional status, potentially impairing wound healing and immune function. However, it is not as directly linked to an increased risk of HAIs as immune suppression or invasive procedures.
D. Receiving vaccinations generally aims to enhance immunity and protect against specific infections. Immunizations can help prevent infections but do not increase the risk of healthcare-associated infections. This action is preventive rather than a risk factor for HAIs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

Correct Answer is A

Explanation

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

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

An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?