A nurse is caring for a client in a long-term care facility.
Vocal quality
Blood pressure
Albumin
BMI
Dentition
Bowel pattern
Lung sounds
Temperature
Secretions
Posture
Correct Answer : A,D,F,G,H,I,J
A. Vocal quality – The client’s voice is hoarse and weak on Day 30, which may indicate dehydration, malnutrition, or an underlying respiratory issue.
B. Blood pressure – The client's blood pressure has slightly decreased but remains within a normal range, so it does not require immediate follow-up.
C. Albumin – Serum albumin levels are still within normal range.
D. BMI – The drop from 20 to 19 suggests unintentional weight loss, which could indicate malnutrition, inadequate intake, or an underlying illness.
E. Dentition –No difficulty in chewing reported.
F. Bowel pattern – The client has constipation for three days, which may require intervention to prevent complications like fecal impaction or discomfort.
G. Lung sounds – Diminished breath sounds at the bases may indicate fluid accumulation, atelectasis, or respiratory infection, requiring further evaluation.
H. Temperature – The client’s fever (38.1°C/100.6°F) suggests a possible infection and requires monitoring for underlying illness.
I. Secretions – Thick oral secretions may indicate dehydration, poor oral hygiene, or a swallowing issue, requiring follow-up to prevent aspiration.
J. Posture – The client’s slumped posture and fatigue could indicate weakness, nutritional deficiencies, or an underlying neurological or musculoskeletal problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","F","G","H","I","J"]
Explanation
A. Vocal quality – The client’s voice is hoarse and weak on Day 30, which may indicate dehydration, malnutrition, or an underlying respiratory issue.
B. Blood pressure – The client's blood pressure has slightly decreased but remains within a normal range, so it does not require immediate follow-up.
C. Albumin – Serum albumin levels are still within normal range.
D. BMI – The drop from 20 to 19 suggests unintentional weight loss, which could indicate malnutrition, inadequate intake, or an underlying illness.
E. Dentition –No difficulty in chewing reported.
F. Bowel pattern – The client has constipation for three days, which may require intervention to prevent complications like fecal impaction or discomfort.
G. Lung sounds – Diminished breath sounds at the bases may indicate fluid accumulation, atelectasis, or respiratory infection, requiring further evaluation.
H. Temperature – The client’s fever (38.1°C/100.6°F) suggests a possible infection and requires monitoring for underlying illness.
I. Secretions – Thick oral secretions may indicate dehydration, poor oral hygiene, or a swallowing issue, requiring follow-up to prevent aspiration.
J. Posture – The client’s slumped posture and fatigue could indicate weakness, nutritional deficiencies, or an underlying neurological or musculoskeletal problem.
Correct Answer is A
Explanation
A. "I should apply clean dressings over the top of blood-saturated dressings and hold pressure.” This prevents disruption of clot formation and controls bleeding.
B. "I can clean wounds with hydrogen peroxide.” Hydrogen peroxide can damage healthy tissue and delay healing.
C. "I can carefully remove the object from a penetrating wound.” Objects should be left in place until medical professionals remove them.
D. "I should place the affected area in a dependent position.” Elevating an injured limb helps reduce swelling and bleeding.
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