Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?

Name of funeral home to contact.

Contact information for client's next of kin.

Health care proxy documentation

Client's wishes regarding organ donation.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Health care proxy documentation.

Choice A rationale:

The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.

Choice B rationale:

While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.

Choice C rationale:

Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves. This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.

Choice D rationale:

The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation. This information is not as immediately critical as the health care proxy documentation during the admission assessment.

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Correct Answer is B

Explanation

PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.

The other options are not correct because:

A. Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.

C. Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after bowel surgery and do not require immediate intervention.

D. Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.

A. A client with diabetes mellitus (DM) develops cellulitis around a foot wound. B. Following suture removal from a client's stab wound, the wound dehisces. C. Following abdominal surgery, a client experiences wound evisceration. D. A client with a stage 4 sacral pressure ulcer develops purulent drainage.

Correct Answer is C

Explanation

The correct answer is Choice C. Following abdominal surgery, a client experiences wound evisceration.

Choice A rationale:

Cellulitis developing around a foot wound in a client with diabetes mellitus (DM) is a concerning situation, but it does not require the most immediate intervention compared to wound evisceration. Cellulitis is a bacterial skin infection that can usually be treated with antibiotics, while wound evisceration is a surgical emergency.

Choice B rationale:

Following suture removal from a stab wound, wound dehiscence is a serious complication, but it is not as immediately life-threatening as wound evisceration. Wound dehiscence is the separation of the wound edges after closure, and while it requires prompt attention, it does not involve the protrusion of organs from the wound.

Choice C rationale:

Wound evisceration, the protrusion of organs through a surgical incision, is a life-threatening complication that requires immediate intervention. The practical nurse should cover the exposed organs with a sterile, moist dressing and seek immediate medical assistance to prevent infection and further complications.

Choice D rationale:

For a client with a stage 4 sacral pressure ulcer developing purulent drainage is a concern, but it is not as immediately critical as wound evisceration. Proper wound care and infection management are essential, but the urgency level is lower compared to wound evisceration.

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Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

When caring for postoperative clients, which situation requires the most immediate intervention by the practical nurse (PN)?

Correct Answer is C

Explanation

A male client atends a community support program for mentally impaired and chemical abusing clients. The client tells the practical nurse (PN) that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?

Which finding for a client with an arteriovenous fistula (AV Fistula) should the practical nurse (PN) report to the healthcare provider?

A 70-year-old male client who is convalescing from a hip replacement is identified as being at risk for developing a pressure ulcer. Which physical characteristic of aging contributes most to this risk factor?

A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

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