A nurse is assisting in the care of a client.

Nurses' Notes Day 1 0800:

Client is alert and oriented

Breath sounds are clear and present throughout. Denies tobacco use.

Client lives in a 20-year-old, one-story house with their partner. Client reports they just returned from an 8-hr car trip. Client eats a high fiber diet and drinks 2,000 mL of

fluid/day.

Day 1,1000:

2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf.

Calf circumference:

Left: 40 cm (15.8 in)

Right: 38.1 cm (15 in)

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing:

lead poisoning

pneumonia

atherosclerosis

constipation

pulmonary embolism

Answer and Explanation

The Correct Answer is B

The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. While calcium supplementation is important for bone health, the recommended daily intake for adults at risk for osteoporosis is typically higher than 250 mg. The client may need a higher dose of calcium supplementation, along with other dietary sources of calcium.
B. While exercise is beneficial for bone health, vigorous exercise may not be suitable for all individuals, especially those at risk for osteoporosis who may have other health
concerns. Moderate-intensity exercise is generally recommended for bone health.

C. Performing moderate-intensity exercise for at least 150 minutes per week is

recommended for individuals at risk for osteoporosis. Weight-bearing and resistance exercises are particularly beneficial for improving bone density and strength.

D. Vitamin D supplementation is important for calcium absorption and bone health, but the recommended daily intake for adults at risk for osteoporosis is typically higher than 400 IU. Many healthcare providers recommend higher doses of vitamin D
supplementation, especially for individuals with low sun exposure or other risk factors for deficiency.

A. Every 30 minutes B. Every 180 minutes C. Every 60 minutes D. Every 120 minutes

Correct Answer is D

Explanation

A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.

C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may

still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?

Correct Answer is D

Explanation

While supervising a student who is manually transferring a patient from bed to chair, a nurse intervenes when the student transfers the patient while

A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

A nurse knows that the major effect of immobility on the gastrointestinal system is the lack of natural movement of the intestines, which is known as

A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?

A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?

When lying in the supine position, the patient's ankles should be flexed approximately 90 degrees so that the toes point toward the ceiling. This is referred to as