Admission Assessment Day 1, 1000:
An older adult client was transferred to the ICU after they developed a fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty. The client is alert and oriented to person, place, and time. The client's partner is at the bedside.
Past Medical History: hypertension, congestive heart failure, Parkinson's disease Allergies: penicillin (anaphylaxis)
Social History: The client has visual loss but didn't bring their glasses. The client is hard of hearing. Hearing aids in place.
Which of the following actions should the nurse take? Select all that apply.
Request that the client's family bring the client's eyeglasses from home.
Reorient the client often.
Acknowledge the client's feelings.
Provide the client with information about what to expect during their care.
Write the full date on the client's whiteboard.
Ask the client's partner to stay with the client as much as possible.
Maintain a well-lit environment.
Request that the client have the same caregivers with every shift.
Correct Answer : A,B,C,D,E,G
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- Request that the client's family bring the client's eyeglasses from home: This is important to ensure that the client has optimal vision and can see clearly, considering their visual loss. Having their eyeglasses will improve their ability to communicate and understand their surroundings.
- Reorient the client often: Reorientation is important for clients who may be disoriented due to their medical condition or unfamiliar environment. Regularly reminding the client of their location, date, and situation can help them maintain orientation.
- Acknowledge the client's feelings: Acknowledging and validating the client's feelings can help establish rapport and promote a therapeutic relationship. It shows empathy and understanding, which can contribute to the client's overall well-being.
- Provide the client with information about what to expect during their care: Providing information to the client about their care helps promote autonomy and active participation in their own healthcare. It can reduce anxiety and improve the client's overall experience.
- Write the full date on the client's whiteboard: Clearly documenting the full date on the client's whiteboard helps the client stay oriented to the current date and time.
- Maintain a well-lit environment: Ensuring a well-lit environment is important, especially for clients with visual impairment. Sufficient lighting can enhance the client's ability to see and navigate their surroundings.
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It's worth noting that while asking the client's partner to stay with the client as much as possible may be beneficial, it may not always be feasible or within the nurse's control. Additionally, requesting the client to have the same caregivers with every shift may not be possible due to staffing constraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Restlessness can be an indicator of unrelieved pain in a client who is receiving a spinal epidural to treat a herniated disc. Restlessness is often a manifestation of discomfort or agitation, which can be caused by inadequate pain management. When a client's pain is not adequately relieved, they may exhibit restlessness as they try to find a more comfortable position or seek relief from the discomfort.
Urinary retention (option A) is incorrect because it can be a side effect of certain medications used in pain management, such as opioids, but it is not a specific indicator of unrelieved pain. It is important to monitor for urinary retention as a potential complication of spinal epidural anaesthesia, but it is not directly related to pain relief.
Constipation (option B) is incorrect because it is another possible side effect of opioid medications, but it is not a specific indicator of unrelieved pain. It is important to address constipation as a potential adverse effect of pain management, but it is not a direct indicator of pain relief.
Difficulty swallowing (option C) is incorrect because it is not a common indicator of unrelieved pain in the context of a spinal epidural. It may be associated with other conditions or complications but is not specifically related to pain relief.
Correct Answer is A
Explanation
Placing soiled dressings in a biohazard trash receptacle is the appropriate practice for disposing of potentially infectious materials. It helps prevent the spread of microorganisms and ensures proper handling and disposal of contaminated items.
Clostridium difficile is a spore-forming bacterium that is not effectively killed by alcohol-based hand rubs. Hand hygiene for C. difficile requires the use of soap and water to thoroughly wash the hands.
Droplet precautions typically require the use of a surgical mask, not a gown and gloves. A gown and gloves are used for contact precautions.
The recommended bleach solution for blood spills is typically a 1:10 dilution, not 1:20. This concentration helps ensure effective disinfection and decontamination of the area.
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