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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.

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Correct Answer is B

Explanation

Prednisone can cause blood glucose levels to increase.

The nurse should explain to the client that the reason for checking his blood glucose level is because prednisone, a medication he is receiving, can cause an increase in blood glucose levels. Prednisone is a corticosteroid medication that is commonly used in the treatment of various conditions, including COPD. It has the potential to raise blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and decreasing insulin sensitivity. Monitoring blood glucose levels is important to assess and manage any potential hyperglycaemia or changes in the client's blood sugar levels while on prednisone.

Older adults are not at increased risk for developing type 1 diabetes mellitus in (option A) is incorrect. Type 1 diabetes is an autoimmune condition that typically occurs in childhood or adolescence, and it is characterized by the destruction of insulin-producing cells in the pancreas.

Albuterol treatments, which are used to relieve bronchospasms in clients with COPD, are not known to cause blood glucose levels to decrease in (option C) is incorrect. Albuterol is a beta-2 adrenergic agonist that primarily acts on the respiratory system and does not have a direct effect on blood glucose levels.

Having COPD does not directly cause blood glucose levels to fluctuate in (option D) is incorrect. While there can be various factors that may indirectly affect blood glucose levels in individuals with COPD (e.g., medications, stress, comorbidities), the primary reason for monitoring blood glucose in this case is the use of prednisone.

In summary, the nurse should explain to the client that the blood glucose levels are being checked because prednisone, a medication he is taking for his COPD, can cause an increase in blood glucose levels. This allows for appropriate monitoring and management of any potential hyperglycemia associated with the use of prednisone.

A. "I should not feed my baby anything for 2 hours prior to an immunization." B. "My baby will receive three doses of the meningococcal immunization before kindergarten." C. “My baby will receive the rotavirus immunization orally." D. "I should expect my baby to have a high fever for 24 hours after an immunization.”

Correct Answer is C

Explanation

"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.

"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.

"My baby will receive three doses of the meningococcal immunization before kindergarten." This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for the specific recommendations regarding the meningococcal immunization.

"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

Correct Answer is C

Explanation

A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?