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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.

Answer and Explanation

Correct Answer : A,B,C,D,E,G

1. 1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

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.

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Correct Answer is D

Explanation

Budesonide is a corticosteroid inhaler used for long-term management of asthma. It helps to reduce inflammation and prevent asthma symptoms. Rinsing the mouth and gargling with water after using a corticosteroid inhaler can help reduce the risk of developing oral thrush, a fungal infection.
The other statements are incorrect and indicate a misunderstanding of the teaching:
"I will take my inhaler treatment before each meal and at bedtime": Budesonide is not typically used before meals or at bedtime. It is usually taken on a regular schedule, as prescribed by the healthcare provider, to provide long-term control of asthma symptoms.
Using the inhaler before exercising is important because physical activity can trigger asthma symptoms in some individuals. By using the inhaler before exercise, the client can help prevent exercise-induced asthma symptoms. However, this depends on the degree of difficulty of the exercise.
"I should use my inhaler when I have an asthma attack": Budesonide is not a rescue inhaler for immediate relief of asthma symptoms during an asthma attack. It is a controlled medication meant to be used regularly to prevent symptoms from occurring.

A. "You should take the medication on an empty stomach to prevent a headache." B. The headaches should decrease as you get used to the medication." C. "Swallow the tablet whole to minimize your headaches." D. "You can discontinue the medication until the headache goes away!"

Correct Answer is B

Explanation

Headaches are a common side effect of isosorbide dinitrate, especially when initially starting the medication. However, they often improve as the body adjusts to the medication. It is important to reassure the client that the headaches should decrease over time. If the headaches persist or worsen, the client should inform their healthcare provider for further evaluation and possible adjustment of the medication regimen.

The statement about taking the medication on an empty stomach is not relevant to preventing headaches associated with isosorbide dinitrate.

The statement about swallowing the tablet whole does not address the issue of headaches. Chewable isosorbide dinitrate is designed to be chewed or dissolved in the mouth, and swallowing it whole may not provide the intended therapeutic effect.

Discontinuing the medication until the headache goes away is not recommended without consulting the healthcare provider. Abruptly stopping or changing the dose of isosorbide dinitrate can have serious consequences and should only be done under medical supervision.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure.

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is helping to place a client into the prone position. The nurse should use a small pillow to relieve pressure from which of the following areas of the client's body?