A nurse is assisting in the care of a client who is postoperative following a hip arthroplasty in the orthopedic unit. The primary health care provider has prescribed pain management and positioning strategies to prevent complications.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for developing
dropdown
due to
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

The correct answer is Constipation / Opioid use.

Constipation is a common side effect of opioid use. The client is receiving oxycodone for pain management, which can slow down the digestive system, leading to constipation.

Pressure injuries, also known as pressure ulcers or bedsores, are a risk due to prolonged immobility. This is especially relevant for a client who is postoperative and has limited movement. However, this was not selected as the primary condition based on the given clues.

Hypoglycemia (low blood sugar) is not directly indicated by the client's current medications or conditions. The client is receiving IV dextrose, but there is no indication of a risk of hypoglycemia in the provided information.

Confusion can occur in clients with cognitive impairments or due to medication side effects, but it is not specifically indicated as a primary risk in this case.

Dysrhythmias (abnormal heart rhythms) can be caused by imbalances in potassium or sodium levels, among other factors, but there is no evidence of such imbalances or related symptoms in this client’s case.

Nursing Test Bank

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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

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Correct Answer is B

Explanation

Choice A rationale

Administering vaginal cream is a medication administration task requiring knowledge and skills within the licensed nurse's scope of practice. Assistive personnel (AP) are not authorized to perform this procedure due to the potential for complications and the need for clinical judgment.

Choice B rationale

Providing postmortem care is a task that AP can perform as it involves basic care activities, such as bathing and positioning, which do not require specialized nursing skills. This allows the nurse to focus on more complex patient needs.

Choice C rationale

Suctioning a tracheostomy is a procedure that requires clinical assessment and intervention skills. Due to the potential for complications, it is within the licensed nurse's scope of practice, not the AP's.

Choice D rationale

Changing a peripheral IV dressing involves assessment skills and requires sterile technique to prevent infection. This task is beyond the scope of practice for AP and should be performed by a licensed nurse.

A. Use a narrower cuff to repeat the BP measurement. B. Request a prescription for an antihypertensive medication. C. Measure the client's BP in the other arm. D. Deflate the cuff faster when repeating the BP measurement.

Correct Answer is C

Explanation

Choice A rationale

Using a narrower cuff can result in an inaccurate blood pressure reading by providing artificially high values due to increased pressure on a smaller surface area.

Choice B rationale

Requesting a prescription for an antihypertensive medication is premature without verifying the accuracy of the initial blood pressure measurement and considering other factors that might have influenced the reading.

Choice C rationale

Measuring the client's blood pressure in the other arm can help confirm the initial reading. Differences in readings between arms can occur, and a second measurement ensures accuracy and proper assessment.

Choice D rationale

Deflating the cuff faster when repeating the blood pressure measurement can lead to inaccurate readings. The cuff should be deflated at a standard rate to ensure reliability and accuracy in the measurement. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.The client's BP was 126/72 mm Hg 15 min ago.The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with an older adult client who has urinary incontinence.Which of the following instructions should the nurse include?

A charge nurse is observing a newly licensed nurse who is caring for a group of clients.Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.The nurse enters the client's room and finds them dressing and stating that they are going home.Which of the following actions should the nurse take?

A nurse is reviewing the laboratory reports of four clients.Which of the following clients should the nurse expect to have a positive fecal occult blood test?

A nurse is collecting data from a client who has diabetes mellitus.The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

A nurse is caring for a client who is dying.One of the client's family members tells the nurse, "I need to help.What can I do?" Which of the following actions should the nurse take?

A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.The employer asks the nurse about the client's condition.Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago.Which of the following actions should the nurse take?