A married woman comes to the clinic for her annual well-woman physical examination. During the interview with the practical nurse (PN), the client makes minimal eye contact. The PN observes yellow bruising to the lower eye and purple bruising on the client's upper arm, which look like fingerprints. Which question is best for the PN to ask the client?

Is anyone hurting you?

Do you want to see a social worker?

How is your marital relationship?

Is there something you want to tell me?

Answer and Explanation

The Correct Answer is A

A. Is anyone hurting you?: This direct question addresses the possibility of abuse clearly and sensitively. Observed bruising patterns and minimal eye contact are potential indicators of intimate partner violence, making this the most appropriate and immediate inquiry.

B. Do you want to see a social worker?: Offering support is important, but it assumes the client has already disclosed abuse. Without first assessing the situation, this approach may not elicit necessary information or provide immediate protection.

C. How is your marital relationship?: Asking generally about the relationship may be too vague to uncover abuse. Clients experiencing violence may not recognize or disclose abusive behavior without direct questioning.

D. Is there something you want to tell me?: While open-ended questions can encourage sharing, this phrasing may be too indirect given the clear physical signs of potential abuse. Direct questioning is needed to ensure the client’s safety.

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Correct Answer is D

Explanation

A. Encourage the client to resume normal activities after medication administration: While pain relief may improve mobility, encouraging normal activity immediately could risk injury. Activity should be guided by pain level and mobility limitations.

B. Observe the client for involuntary movements of the lips and tongue: Involuntary movements are more commonly associated with long-term opioid use or neurological conditions, not a typical short-term adverse effect of hydrocodone/acetaminophen.

C. Assess the skin daily for areas of ecchymosis or other signs of bleeding: While monitoring for bruising is appropriate for trauma, it is not directly related to the administration of hydrocodone/acetaminophen.

D. Implement ongoing assessments for signs of shallow or slow breathing: Opioids like hydrocodone can depress the respiratory system. Monitoring for respiratory depression, especially after initial doses, is a critical safety intervention to prevent hypoxia and other complications.

A. Provide gentle and meticulous mouth care. B. Keep the room environment free of unpleasant odors. C. Assist the client with feeding at meal times. D. Gather supplies for protective environment precautions.

Correct Answer is A

Explanation

A. Provide gentle and meticulous mouth care: Stomatitis causes painful inflammation and ulceration of the oral mucosa. Gentle, thorough oral care reduces the risk of infection, promotes healing, and helps maintain oral hygiene, making this the most important instruction for the UAP.

B. Keep the room environment free of unpleasant odors: Minimizing odors can help with nausea, but it does not directly address stomatitis care. This is a supportive measure, not a primary intervention.

C. Assist the client with feeding at meal times: Assistance with feeding is helpful for comfort and nutrition, but it does not directly manage the oral lesions or reduce infection risk.

D. Gather supplies for protective environment precautions: Protective environment precautions are primarily used for clients with severe immunosuppression. While important in some chemotherapy settings, the key intervention for stomatitis is proper oral care.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client with fractured metatarsals after slamming a hand in the car door After administering the prescribed hydrocodone/acetaminophen for pain, which intervention should the PN include in the client's care?

Correct Answer is D

Explanation

A client who is receiving chemotherapy has developed stomatitis. Which instruction should the practical nurse (PN) provide the unlicensed assistive personnel (UAP) who is assisting with the care of this client?

Correct Answer is A

Explanation

The practical nurse (PN) is caring for a client with a nasogastric tube. Which directions should the PN give to the unlicensed assistive personnel (UAP)?

The practical nurse (PN) is providing care for a client who is NPO after a small bowel resection. The client's NG tube is connected to low intermittent suction. The client reports dizziness and tingling in digits. Which assessment finding by the PN should be reported to the healthcare provider.

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

At the beginning of the shift, in which order of priority should the practical nurse (PN) assess these four clients? (Arrange from highest priority first to lowest priority last.)

A client who is receiving sodium polystyrene sulfonate reports having two watery stools since starting the medication the previous day. Which action should the practical nurse (PN) take?

The practical nurse (PN) plans to administer a PRN dose of loperamide via a client's gastrostomy tube. The prescribed dose is 3 mg. The label on the medication bottle reads, "1 mg/5 mL." How many mL should the PN administer? (Enter numeric value only.)

The practical nurse (PN) observes that an unlicensed assistive personnel (UAP) is preparing to disconnect a client's IV tubing to remove the client's hospital gown during a bed bath. Which action should the PN implement?