Try Naxlex NCLEX-RN (Free-Trial)

Admission Assessment Day 1, 1000:

An older adult client was transferred to the ICU after they developed 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: 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. 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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

This step is part of the process when mixing NPH and regular insulin in a single syringe. After injecting air into the NPH insulin vial, you should inject an equal amount of air (in this case, 15 units) into the regular insulin vial to maintain pressure balance. This allows for easy withdrawal of the prescribed doses of each insulin type in the same syringe without causing a vacuum in the vials.

After injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.

Verifying the dosage with another nurse is not necessary in this step, as it is done prior to drawing up the insulin. However, it is good practice to have another nurse double-check the dosage before administration.

Injecting air into the regular insulin vial is not required at this stage. It is only necessary when withdrawing the regular insulin dose.

Placing the cap over the needle should be done after withdrawing the desired dose of insulin and before administering it to the client for safety and to prevent needlestick injuries.

The correct sequence when mixing NPH and regular insulin in a single syringe is as follows:

Inject air into the NPH insulin vial (in this case, 10 units of air).
Inject air into the regular insulin vial (in this case, 15 units of air).
Withdraw the prescribed dose of NPH insulin (10 units) from the NPH vial.
Withdraw the prescribed dose of regular insulin (15 units) from the regular insulin vial.

So, after injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.

A. Cantaloupe B. Sweet potato C. Orange juice D. Baked chicken breast

Correct Answer is D

Explanation

Potassium is an essential electrolyte that plays a crucial role in various bodily functions. However, for individuals with an electrolyte imbalance, it is often necessary to limit their potassium intake. Among the options provided, baked chicken breast is the lowest in potassium. Cantaloupe is relatively high in potassium. A cup of diced cantaloupe contains about 430 mg of potassium.

Sweet potatoes are known for their high potassium content. A medium-sized sweet potato with skin contains about 542 mg of potassium.

Orange juice also contains a moderate amount of potassium. An 8-ounce serving of orange juice typically contains around 450 mg of potassium.

Chicken breast is naturally low in potassium compared to fruits and vegetables. It contains about 260 mg of potassium per 4-ounce serving.

Therefore, among the given options, the baked chicken breast is the lowest in potassium and would be the most suitable choice for a client with an electrolyte imbalance requiring a low-potassium diet.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

Correct Answer is B

Explanation

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?

Correct Answer is D

Explanation

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxyphenol-methamphetamine. Which of the following findings should the nurse expect?

A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the- counter products as unsafe for use with enoxaparin?

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?