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A nurse on a medical-surgical unit is admitting a client.

Exhibits

Click to highlight the action that would be appropriate for the care of the client. Each body system may support more than 1 potential action. To deselect an action, click on the action again.

Body System

Action

Cardiopulmonary

Inform client to achieve two to four breaths per session when using incentive spirometer.

Encourage deep-breathing exercises.

Check for pain.

Gastrointestinal

Encourage the client to increase fiber in their diet.

Promote intake of oral fluids.

Apply barrier ointment after bowel movements.

Encourage deep-breathing exercises

Check for pain

Promote intake of oral fluids

Apply barrier ointment after bowel movements

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Cardiopulmonary:

Encourage deep-breathing exercises.
Check for pain.

Rationale:

Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.

Checking for pain is essential as the client has been prescribed PRN morphine for pain management.

"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.

Gastrointestinal:

Promote intake of oral fluids.
Apply barrier ointment after bowel movements.

Rationale:

Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.

Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.

"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "Direct all communication through the client's family." While family members may assist in communication, they may omit, alter, or misunderstand medical information. Using a trained medical interpreter ensures accurate and confidential communication.
B. "Limit instructions to simple and short one-sentence instructions." While clear, simple instructions are helpful, language barriers still exist. This does not fully address the client’s difficulty in understanding.
C. "Ask a coworker who speaks the client's language to translate information." A coworker may not be a certified medical interpreter and could misinterpret critical information. Medical translation should always be done by a qualified interpreter.
D. "Find an available interpreter to help with communication." A trained medical interpreter provides accurate, unbiased, and professional translation, ensuring that the client fully understands their care and can make informed decisions.

A. Plan to assign a different nurse to the client each shift. B. Start discharge planning on the day of admission. C. Request that the client complete a satisfaction survey at discharge. D. Limit the number of interdisciplinary team members managing the client's care.

Correct Answer is B

Explanation

A. Plan to assign a different nurse to the client each shift. Assigning different nurses each shift disrupts continuity of care. Whenever possible, consistent nursing assignments improve client outcomes.
B. Start discharge planning on the day of admission. Discharge planning should begin upon admission to ensure a smooth transition of care, reduce hospital readmissions, and promote better long-term outcomes.
C. Request that the client complete a satisfaction survey at discharge. While client feedback is valuable, it does not directly contribute to continuity of care during the hospital stay.
D. Limit the number of interdisciplinary team members managing the client's care. Interdisciplinary collaboration (e.g., physicians, nurses, physical therapists, social workers) is crucial in providing comprehensive and continuous care, especially for complex cases.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a different language and is having difficulty understanding them. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?

Correct Answer is B

Explanation

44. A nurse is preparing to provide foot care for a client who is ambulatory. Identify the sequence of steps the nurse should follow when performing foot care. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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A nurse is creating a plan of care for a client who has left-sided hemiplegia. Which of the following interventions should the nurse include?

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A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?

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