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.

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Correct Answer is D

Explanation

Choice A reason: Low-protein, low-potassium diet

A low-protein, low-potassium diet is not typically recommended for acute glomerulonephritis. While protein intake may need to be moderated to reduce the workload on the kidneys, potassium restriction is usually not necessary unless there is hyperkalemia (high potassium levels) present. The primary dietary focus should be on managing fluid and sodium intake to control edema and hypertension.

Choice B reason: Regular diet, no added salt

A regular diet with no added salt is a step in the right direction but may not be sufficient for managing acute glomerulonephritis with significant edema. Sodium restriction is crucial to help reduce fluid retention and control blood pressure. Therefore, a more stringent low-sodium diet is often necessary.

Choice C reason: Low-carbohydrate, low-protein diet

A low-carbohydrate, low-protein diet is not appropriate for managing acute glomerulonephritis. Carbohydrate intake does not directly impact kidney function in this context, and protein intake should be moderated rather than severely restricted. The focus should be on sodium and fluid management.

Choice D reason: Low-sodium, fluid-restricted diet

A low-sodium, fluid-restricted diet is the most appropriate choice for a client with acute glomerulonephritis and peripheral edema. Reducing sodium intake helps to minimize fluid retention and control blood pressure, while fluid restriction helps to prevent further edema and manage the workload on the kidneys. This dietary approach is essential for managing the symptoms and complications associated with acute glomerulonephritis.

A. Apply intermittent ice to the affected ankle for the first 48 hours. B. Wrap the affected ankle with an elasticized compression bandage. C. Apply full weight-bearing on the affected ankle. D. Elevate the affected ankle above the level of the heart. E. Apply a heating pad intermittently to the affected ankle after 48 hours.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Apply intermittent ice to the affected ankle for the first 48 hours

Applying ice intermittently to the affected ankle for the first 48 hours helps reduce swelling and inflammation. Ice should be applied for 15-20 minutes every 2-3 hours during the initial phase of injury management. This practice is part of the RICE (Rest, Ice, Compression, Elevation) protocol commonly used for sprains and strains.

Choice B reason: Wrap the affected ankle with an elasticized compression bandage

Wrapping the affected ankle with an elasticized compression bandage helps to minimize swelling and provide support to the injured area. Compression bandages should be snug but not too tight to avoid restricting blood flow. This is another component of the RICE protocol.

Choice C reason: Apply full weight-bearing on the affected ankle

Applying full weight-bearing on the affected ankle is not recommended immediately after a second-degree sprain. The ankle needs time to heal, and weight-bearing should be gradually reintroduced as pain and swelling decrease. Initially, the client should avoid putting weight on the injured ankle to prevent further damage.

Choice D reason: Elevate the affected ankle above the level of the heart

Elevating the affected ankle above the level of the heart helps reduce swelling by promoting venous return and decreasing fluid accumulation in the injured area. This is an essential part of the RICE protocol and should be done as much as possible during the first 48 hours.

Choice E reason: Apply a heating pad intermittently to the affected ankle after 48 hours

Applying a heating pad intermittently to the affected ankle after 48 hours can help increase blood flow and promote healing. Heat therapy should be used after the initial acute phase (first 48 hours) when swelling has subsided. Heat can help relax muscles and reduce stiffness in the injured area.

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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 school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?

Correct Answer is D

Explanation

A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

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