A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours.

Which action should the nurse take?

Place the client on contact precautions.

Start a high-fiber diet.

Administer an oral steroid.

Make the client NPO.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.
Choice B rationale
Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.
Choice C rationale
Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.
Choice D rationale
Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.

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Correct Answer is C

Explanation

Choice A rationale
Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of proper crutch walking technique. Proper crutch walking involves more than just equipment inspection.
Choice B rationale
Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not directly demonstrate an understanding of the correct crutch gait. The focus should be on the actual technique of using the crutches.
Choice C rationale
Bearing body weight on the palms of hands during the crutch gait is the correct behavior that indicates an understanding of proper crutch walking. This technique helps distribute weight appropriately and prevents strain on the underarms, which can cause nerve damage and discomfort.
Choice D rationale
Progressing to foot touchdown and weight bearing of the affected leg is not appropriate for a three-point gait, which is used when the client should not bear any weight on the affected leg. This choice indicates a misunderstanding of the correct crutch walking technique for this specific gait.

Correct Answer is []

Explanation

The correct answer is Potential Condition:

A. Secretory diarrhea.

Actions to Take:

A. Collect stool for culture.

D. Make the client NPO.

Parameters to Monitor:

A. Heart rate.

B. Serum potassium.

Potential Condition A rationale:

Secretory diarrhea is characterized by large volumes of watery stool and can be caused by infections, toxins, or certain medications. It is important to identify the underlying cause to provide appropriate treatment. Potential Condition B rationale:

Steatorrhea is characterized by fatty stools and is typically associated with malabsorption syndromes. The client’s symptoms do not suggest this condition. Potential Condition C rationale:

Motility diarrhea is caused by rapid transit of stool through the intestines, often due to conditions like irritable bowel syndrome. The client’s symptoms are more consistent with secretory diarrhea. Potential Condition D rationale:

Osmotic diarrhea occurs when non-absorbable substances draw water into the intestines. The client’s symptoms are more indicative of secretory diarrhea. Action A rationale:

Collecting stool for culture helps identify any infectious agents that may be causing the diarrhea, allowing for targeted treatment. Action B rationale:

Starting a high-fiber diet is not appropriate for a client with acute diarrhea, as it may exacerbate symptoms. Action C rationale:

Administering an oral steroid is not indicated for the treatment of secretory diarrhea and may worsen the condition. Action D rationale:

Making the client NPO (nothing by mouth) helps to rest the gastrointestinal tract and reduce the severity of diarrhea. Parameter A rationale:

Monitoring heart rate is important as dehydration from diarrhea can lead to tachycardia. Parameter B rationale:

Monitoring serum potassium is crucial as diarrhea can lead to significant electrolyte imbalances, including hypokalemia. Parameter C rationale:

Monitoring respiratory rate is not directly related to the management of diarrhea. Parameter D rationale:

Monitoring urine sodium is not directly related to the management of diarrhea.

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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours.

Which action should the nurse take?