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. The list of medications is typically included in the Background component of the ISBARR communication tool, as it provides important information about the client's ongoing treatment and medications.

B. Treatment plans and interventions are generally discussed in the Assessment and Recommendation components of the ISBARR communication tool, as they involve the nurse's assessment of the client's condition and the actions recommended for continued care.
C. The Situation component of the ISBARR communication tool focuses on providing a concise summary of the client's current medical condition or status, including relevant changes since the last report or significant events that occurred during the shift.
D. Vital signs may be included as part of the Background or Assessment components of the ISBARR communication tool, depending on their relevance to the client's current condition and any changes observed during the shift.

A. Lateral position B. Dorsiflexion C. Contracture D. Plantar flexion

Correct Answer is B

Explanation

A. The lateral position refers to lying on one side with the top hip and knee flexed and the bottom hip and knee slightly flexed.
B. Dorsiflexion is the movement of the ankle joint in which the toes are brought closer to the shin or upward, as in the supine position described.
C. Contracture refers to the shortening or tightening of muscles, resulting in the inability to move the affected joint fully.
D. Plantar flexion is the movement of the ankle joint in which the toes are pointed downward or away from the shin, opposite to the position described.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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

Correct Answer is B

Explanation

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?

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?

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?

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

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 caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?

A patient begins to fall during ambulation. The nurse would

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