A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Report the findings to the healthcare provider.

Review the client's current electrolyte values.

Demonstrate the use of an incentive spirometer.

Connect the tube to low intermittent suction.

Answer and Explanation

The Correct Answer is A

A.   The development of a fever and dyspnea in a client receiving continuous tube feeding could indicate a serious complication, such as aspiration pneumonia, infection, or another significant issue. Reporting these findings to the healthcare provider is crucial for further assessment, diagnosis, and intervention.
B.   While monitoring electrolyte values is important in clients receiving tube feedings, especially if there are concerns about dehydration or imbalances, it is not the immediate priority in this scenario. The client's fever and dyspnea suggest an acute issue that needs prompt attention, and addressing the acute symptoms and reporting them to the healthcare provider takes precedence over reviewing electrolytes.
C.   An incentive spirometer is useful for improving lung function and preventing atelectasis, particularly in postoperative or immobile patients. However, the presence of fever and dyspnea could indicate a more urgent problem such as aspiration or infection, which requires immediate medical evaluation and intervention.
D.   Connecting the tube to low intermittent suction is typically used to decompress the stomach in cases of gastric distension or to prevent aspiration of gastrointestinal contents. However, in the context of the client's new onset of fever and dyspnea, this action does not directly address the potential underlying cause, which could be more serious.

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Correct Answer is C

Explanation

A. Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B. Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C. Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D. Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

A. Tilt the pelvis forwards and backwards. B. Turn the head to the right and left. C. Bend the arm by flexing the ulnar to the humerus. D. Extend the arm at the side and rotate in circles.

Correct Answer is C

Explanation

A. Tilting the pelvis forwards and backwards involves movements of the pelvic girdle, which is more related to the actions of the hip joints and lumbar spine, rather than hinge joints specifically. This action involves the pelvic tilt and is not an exercise for hinge joints like the elbow or knee.
B. Turning the head to the right and left involves rotation of the cervical spine and is associated with pivot joints rather than hinge joints. This action does not involve flexion and extension typical of hinge joints, which are primarily the elbow and knee.
C. This action involves bending the arm at the elbow joint, which is a classic example of a hinge joint. The elbow allows for flexion (bending) and extension (straightening) movements, making it a key example of a hinge joint. This is the correct action for exercising hinge joints.
D. Extending the arm and rotating in circles involves movements of the shoulder joint, which is a ball- and-socket joint, not a hinge joint. The shoulder joint allows for a wide range of movements including circumduction, which is different from the simple flexion and extension movements of hinge joints.

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A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is C

Explanation

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