A nurse in a provider's clinic is assisting in the care of an older adult female client.

Exhibits

For each provider prescription click to specify if the provider prescription is expected or unexpected for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Physical therapy for muscle-strengthening and balance-training

Calcium 1500 mg po once daily on empty stomach

Vitamin D supplement 2.500 units daily

Home health evaluation of home safety

Increase caffeine intake

Increase daily sun exposure

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

A.   Physical therapy for muscle-strengthening and balance-training is expected because the client has a left lateral malleolus fracture and a Bone Mineral Density DEXA scan of -3.8. Physical therapy can help with rehabilitation and prevent future falls.
B.   Calcium supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Calcium supplementation is essential for bone health.
C.   Vitamin D supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Vitamin D supplementation is essential for calcium absorption and bone health.
D.   A home health evaluation of home safety is expected because the client lives alone and has a history of falling. A home health evaluation can help identify potential hazards and improve safety.
E.   Increasing caffeine intake is unexpected because the client already reports consuming at least 3 cups of coffee daily. Increasing caffeine intake further may not be advisable due to potential side effects, such as increased heart rate and blood pressure.
F.   Increasing daily sun exposure is unexpected because the client has osteoporosis and a history of falling. Excessive sun exposure can increase the risk of skin cancer, and the client may not be able to safely spend extended periods of time in the sun due to mobility limitations. Additionally, vitamin D supplementation is usually recommended over sun exposure for individuals with osteoporosis.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A,D,B,C,E

Explanation

A. Unlock and remove the inner cannula is the first step because it allows access to the inner cannula for cleaning.
B. Scrub the inside and outside of the inner cannula with a small brush is the third step because it removes debris and secretions from the inner cannula.
C. Wipe the inside of the inner cannula with a folded pipe cleaner is the fourth step because it further cleans the inner cannula.
D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin is the second step because it provides the solution for cleaning the inner cannula.

E. Cleanse the stoma site with 0.9% sodium chloride solution is the final step because it cleans the stoma site before replacing the inner cannula.

A. Request a prescription renewal from the provider every 36 hr. B. Check the client's range of motion every 6 hr. C. Secure the restraints with a square knot. D. Make sure two fingers fit under the restraints.

Correct Answer is D

Explanation

Rationale:

A. Wrist restraint orders typically require renewal every 24 hours, not every 36 hours.

B. Checking the client's range of motion every 6 hours is not specific to the use of wrist restraints.

C. Secure the restraints with a quick-release knot, not a square knot, to allow for quick removal in case of emergency.

D. Making sure two fingers fit under the restraints is important to ensure that they are not too tight and do not cause injury to the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,D,B,C,E

Explanation

A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?

A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?

A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?