A nurse is caring for four clients. Which of the following should the nurse assess first?

A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness

A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL

A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0 to 10

A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Answer and Explanation

The Correct Answer is A

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

a. Establishing communication between providers:

Telehealth can facilitate communication between healthcare providers, allowing them to consult, collaborate, and share information about patient care remotely. This includes discussing patient cases, sharing test results, and coordinating treatment plans.

b. Developing client treatment protocols:

While telehealth may involve the use of protocols and guidelines to guide care delivery, its primary objective is to provide healthcare services remotely rather than developing treatment protocols specifically.Treatment protocols are typically established during a comprehensive assessment, which telehealth can be a part of, but it's not the sole purpose of a client call

c. Assessing client needs:

This is a core objective of telehealth. It allows healthcare professionals to evaluate the client's current health status, gather relevant information, and determine the necessary next steps in their care remotely.

d. Providing medication reconciliation:

Telehealth can facilitate medication reconciliation by allowing healthcare providers to review a patient's medication list remotely, update medication records, and reconcile any discrepancies during virtual appointments.

A. “I will wear a surgical mask within 3 feet of the client.” B. “I will check that the room has a high-efficiency particulate air filtration system.” C. “I will wear an N95 respirator when providing care for the client.” D. “I will assign the client to a room with positive airflow.”

Correct Answer is A

Explanation

a. "I will wear a surgical mask within 3ft of the client":

This statement is correct. Wearing a surgical mask within 3 feet of the client helps prevent the transmission of respiratory droplets from the client to the healthcare provider or others in close proximity.

b. "I will check that the room has a high-efficiency particulate air filtration system":

This statement is not directly related to implementing droplet precautions. While a high-efficiency particulate air (HEPA) filtration system can help improve air quality in a healthcare setting, it is not a standard requirement for implementing droplet precautions.

c. "I will wear an N95 respirator when providing care for the client":

This statement is not accurate for implementing droplet precautions for influenza. N95 respirators are used for airborne precautions, which are indicated for diseases transmitted by smaller droplet nuclei (e.g., tuberculosis). Surgical masks are typically sufficient for preventing the transmission of respiratory droplets during care for clients with influenza.

d. "I will assign the client to a room with positive airflow":

This statement is not appropriate for implementing droplet precautions. Positive airflow rooms are typically used for clients requiring airborne precautions to prevent the spread of infectious agents in the air. In the case of influenza, droplet precautions are sufficient, and assigning the client to a room with standard airflow is appropriate.

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A nurse is caring for four clients. Which of the following should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth?

Correct Answer is C

Explanation

A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes mellitus. The client tells the nurse she has decided to go home. Which of the following actions should the nurse take?

A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?

A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?

A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event?

A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?

A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take?

A charge nurse is observing a newly licensed nurse use aseptic technique when irrigating a client’s open abdominal wound. The charge nurse should intervene for which of the following actions by the newly license nurse?

Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?