A nurse is collaborating with the interprofessional team and reviewing a client's electronic medical record of a post-operative client.
Click to highlight the findings that the nurse should recommend be addressed by the case manager. To deselect a finding, click on the finding again.
Nurses' Notes
1315:
Client is postoperative following an open cholecystectomy. Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment.
Plan of Care
1300:
Case management referral for discharge planning. Client will need home health referral for dressing changes. Client to follow up with the provider at the clinic in one week.
Client's partner is at bedside
dressing intact
small amount of serosanguineous drainage on dressings
reports pain as 5
Client requests a dose of their pain medication
expresses concern regarding the cost of prescription medications
unable to find transportation
home health referral
The Correct Answer is ["D","E","F","G","H"]
Rationale
- Client reports pain as 5 on a scale of 0 to 10. The case manager can work with the healthcare team to ensure adequate pain management strategies are in place.
- Client requests a dose of their pain medication. This indicates ongoing pain and the need for effective pain management.
- Client expresses concern regarding the cost of prescription medications. The case manager can assist with identifying affordable medication options or connecting the client with financial assistance programs.
- Client reports being unable to find transportation to follow-up appointment. The case manager can help arrange transportation or connect the client with community resources that can provide transportation assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Waiting 2 minutes between suction passes allows the client to recover and helps to prevent hypoxia, demonstrating an understanding of the suctioning procedure.
B. Wearing clean gloves during suctioning is not appropriate; sterile gloves should be used to prevent introducing pathogens into the airway.
C. The recommended suction pressure for adults is typically between 80 and 120 mm Hg; therefore, setting the suction to 200 mm Hg is too high and could cause trauma to the airway.
D. Suction should be applied only while withdrawing the catheter, not while inserting it, to minimize trauma and prevent oxygen deprivation.
Correct Answer is ["A","D"]
Explanation
A. Client 1: The client with Pertussis should have individuals wear surgical masks when within 3 feet of the client, not 1 foot. Pertussis is highly contagious, and proper precautions are necessary to prevent transmission
B. Client 2: The client with Clostridium difficile is placed in a private room, and nurses wear gowns and gloves during direct care. These are appropriate contact precautions for preventing the spread of C. difficile.
C. Client 3: The client with Herpes simplex is managed with nurses wearing gowns and gloves during direct care, which is appropriate for preventing the spread of the virus through direct contact.
D. Client 4: The client with Mycobacterium tuberculosis should be placed in a negative airflow room, not a positive airflow room. Negative airflow rooms help contain airborne pathogens and prevent them from spreading to other areas.
E. Client 5: The client with Streptococcal pharyngitis is placed in a private room, and the client wears a surgical mask when transported outside their room. These are appropriate droplet precautions to prevent the spread of infection.
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