A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD and peripheral vascular disease (PVD is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement?

Reinforce the need for adequate hydration.

Provide typed instructions for healthy diet selections.

Explain a daily regimen.

Demonstrate specific strengthening exercises.

Answer and Explanation

The Correct Answer is A

A. Reinforce the need for adequate hydration: Adequate hydration is essential for liquefying secretions in the lungs, especially in clients with COPD who may have increased mucus production. Proper hydration also supports cardiovascular function, particularly in clients with peripheral vascular disease.

B. Provide typed instructions for healthy diet selections: While diet is important for overall health, hydration is the priority in this scenario due to the client's respiratory and vascular conditions.

C. Explain a daily regimen: While educating the client about a daily regimen is important, ensuring adequate hydration takes precedence in this situation.

D. Demonstrate specific strengthening exercises: While exercise is beneficial for clients with COPD and PVD, ensuring proper hydration is more critical for respiratory and cardiovascular function in this scenario.

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Correct Answer is A

Explanation

A. Provide disposable training pants while calming the mother: This option addresses the

immediate need to provide comfort and support to the child and mother. Offering disposable

training pants can help manage the situation while the nurse addresses the mother's distress and educates her about age-appropriate toilet training expectations.

B. Refer the mother to a community parent education program: While parent education programs can be beneficial, they are not the initial action needed in this situation, which requires
immediate intervention to support the child and mother.
C. Suggest that the mother consult a pediatric nephrologist: Referring the mother to a pediatric nephrologist may not be necessary at this point, as wetting accidents are common in young
children during the toilet training process. The nurse should first address the immediate emotional needs of the child and mother.
D. Inform the mother that toilet training is slower for boys: While it's true that toilet training can vary in timing for different children, simply providing this information to the mother may not be sufficient in addressing the distressing situation at hand.

A. When the client has ankle edema. B. Within the first trimester of pregnancy. C. If the client has an elevated blood pressure. D. During admission to labor and delivery.

Correct Answer is C

Explanation

A. When the client has ankle edema Ankle edema may indicate fluid retention, which is common during pregnancy but is not directly related to the assessment of deep tendon reflexes (DTRs).

B. Within the first trimester of pregnancy: Assessing DTRs within the first trimester of pregnancy is not specifically indicated unless there are other signs or symptoms of concern.

C. If the client has an elevated blood pressure: Assessment of DTRs is particularly important if the client has an elevated blood pressure, as it may indicate preeclampsia, a serious pregnancy complication characterized by hypertension and proteinuria.

D. During admission to labor and delivery: While assessment of DTRs may be included in the admission assessment to labor and delivery, it is particularly important to assess DTRs if the client has an elevated blood pressure, as it may indicate preeclampsia.

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A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD and peripheral vascular disease (PVD is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year- old son for wetting his pants. What initial action should the nurse take?

Correct Answer is A

Explanation

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is C

Explanation

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

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