A nurse is admitting a client to a medical-surgical unit following a fall at home.

Exhibits

The nurse is discussing the client’s treatment plan with a provider. For each potential provider’s prescription, specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Administer spironolactone

Administer an IV fluid bolus

Obtain an x-ray of the right hip

Administer an iron supplement

Obtain the client’s weight

Administer supplemental oxygen

Answer and Explanation

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

Potential Prescription	Anticipated	Nonessential	Contraindicated
Administer spironolactone			✅
Administer an IV fluid bolus	✅
Obtain an x-ray of the right hip	✅
Administer an iron supplement		✅
Obtain the client’s weight	✅
Administer supplemental oxygen		✅

Choice A: Administer spironolactone

Spironolactone is a potassium-sparing diuretic used to manage heart failure and hypertension. However, the client’s potassium level is elevated at 5.3 mEq/L (normal range: 3.5 to 5 mEq/L) . Administering spironolactone could exacerbate hyperkalemia, leading to dangerous cardiac arrhythmias. Additionally, the client’s low blood pressure (89/60 mm Hg) and dehydration (indicated by dry skin and tenting) make the use of a diuretic inappropriate as it could further lower blood pressure and worsen dehydration .

Choice B: Administer an IV fluid bolus

The client presents with signs of dehydration (dry skin, tenting, low urine output) and hypotension (BP 89/60 mm Hg). An IV fluid bolus is anticipated to restore intravascular volume, improve blood pressure, and address

dehydration . This intervention is crucial to stabilize the client’s hemodynamic status and improve perfusion to vital organs .

Choice C: Obtain an x-ray of the right hip

The client reports pain in the right hip following a fall, which raises the suspicion of a fracture. An x-ray is essential to diagnose any potential fractures or dislocations, which are common in elderly patients after a fall 5.

Prompt imaging will guide appropriate management and prevent further complications .

Choice D: Administer an iron supplement

While the client has a history of iron-deficiency anemia and is on ferrous sulfate, the immediate need for iron supplementation is nonessential in the context of acute management of the fall and dehydration. The client’s hemoglobin (16 g/dL) and hematocrit (47%) are within normal ranges, indicating that anemia is currently well- managed . The focus should be on stabilizing the client’s acute condition.

Choice E: Obtain the client’s weight

Obtaining the client’s weight is anticipated as it is a critical parameter for calculating medication dosages, fluid requirements, and monitoring the client’s overall health status. Accurate weight measurement is particularly important in elderly patients with multiple comorbidities to ensure precise and safe medical management .

Choice F: Administer supplemental oxygen

The client’s oxygen saturation is 95% on room air, which is within the normal range (95-100%) . Therefore, administering supplemental oxygen is nonessential unless there is evidence of hypoxia or respiratory distress. The primary focus should be on addressing dehydration and hypotension.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Providing the client with articles from the internet that explain colon cancer stages is not the best approach. While it is important for the client to understand their condition, the nurse should ensure that the information is accurate and tailored to the client’s specific situation. Additionally, the nurse should facilitate a direct conversation between the client and the healthcare provider to address any questions or concerns.

Choice B reason: Encouraging the client to write down questions to ask the provider is an excellent approach. This empowers the client to actively participate in their care and ensures that they have a clear understanding of their diagnosis and treatment options. It also helps the client to remember important questions during their consultation with the provider.

Choice C reason: Explaining the various options available for treatment based on the cancer stage is not within the nurse’s scope of practice. Detailed discussions about treatment options should be conducted by the healthcare provider, who has the expertise to provide accurate and comprehensive information tailored to the client’s specific medical condition.

Choice D reason: Assuring the client that the provider will explain what has been planned is a supportive response, but it does not actively engage the client in their care. While it is important to reassure the client, the nurse should also encourage the client to prepare questions and participate in discussions with the provider to ensure they fully understand their treatment plan.

A. Apply a heat lamp twice a day. B. Reposition the client at least every 2 hours. C. Massage reddened areas with dressing changes. D. Clean the wound with hydrogen peroxide solution.

Correct Answer is B

Explanation

Choice A reason:

Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.

Choice B reason:

Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.

Choice C reason:

Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.

Choice D reason:

Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Choice B: Administer an IV fluid bolus

Choice C: Obtain an x-ray of the right hip

Choice D: Administer an iron supplement

Choice E: Obtain the client’s weight

Choice F: Administer supplemental oxygen

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse about what the provider might be planning to do. Which of the following nursing responses should the nurse make?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

A nurse in an outpatient mental health clinic is treating a client who has bulimia nervosa. Exhibits A nurse is assessing the client during a follow-up visit. Select the 4 assessments that indicate a therapeutic response to the treatment plan.

A nurse is teaching a client about the uses of chamomile. Which of the following information should the nurse include in the teaching?

A nurse is preparing to develop a plan of care for a school-aged child who has been hospitalized. Exhibits A nurse should identify that the child has developed dropdown due to dropdown.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives?

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?