After reviewing the admission assessment of a client, which intervention(s) should the nurse include in this client’s plan of care? (Select all that apply)

Implement a 24-hour schedule of routine administration of prescribed analgesic.

Encourage increased fluid intake and measure urinary output every 8 hours.

Assist the client to ambulate as much as possible during waking hours.

Provide comfort measures such as topical warm application and tactile massage.

Determine client’s subjective measure of pain using a numerical scale.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: A 24-hour routine analgesic schedule may lead to overmedication or undermedication, as pain varies. PRN dosing based on pain assessment (e.g., numerical scale) is more appropriate. Routine administration disregards individual pain patterns, risking adverse effects or inadequate relief, making this intervention less suitable for inclusion.

Choice B reason: Encouraging fluid intake and measuring urinary output promotes hydration and monitors renal function, critical for clients with systemic issues or medications affecting kidneys. This intervention supports physiological stability, prevents complications like dehydration, and provides data for care adjustments, making it essential for the plan of care.

Choice C reason: Assisting with ambulation enhances circulation, prevents complications like thrombosis, and supports recovery. For clients with mobility limitations, guided ambulation during waking hours improves strength and independence. This intervention aligns with rehabilitation goals, making it a key component of a comprehensive care plan.

Choice D reason: Comfort measures like warm application and tactile massage reduce pain and stress non-pharmacologically. These interventions improve client comfort, promote relaxation, and complement other pain management strategies. Including them in the care plan supports holistic care, addressing both physical and emotional needs effectively.

Choice E reason: Using a numerical pain scale quantifies subjective pain, guiding tailored interventions. Regular assessment ensures timely analgesic administration and evaluates treatment efficacy. This intervention is critical for pain management, aligning with evidence-based practice to optimize client comfort and recovery, making it essential for the care plan.

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 D

Explanation

Choice A reason: Weakened cough effort increases aspiration risk but does not directly impact the Braden scale, which assesses pressure ulcer risk through factors like moisture, mobility, and nutrition. Cough effort is unrelated to skin integrity, so recalculating the Braden score is unnecessary, as it does not affect ulcer risk factors.

Choice B reason: Hypoactive bowel sounds suggest reduced gastrointestinal motility but do not directly influence Braden scale factors like moisture or mobility. The scale focuses on pressure ulcer risk, and bowel sounds are not a primary contributor. Recalculation is not warranted, as this condition does not alter skin breakdown risk significantly.

Choice C reason: Plus two ankle edema may affect mobility, a Braden scale factor, but is less directly linked to pressure ulcer risk than incontinence. Edema does not typically cause moisture-related skin breakdown. Recalculation may be considered, but it is less urgent than addressing incontinence, which poses a greater risk.

Choice D reason: Urinary incontinence increases moisture, a key Braden scale factor, elevating pressure ulcer risk. Wet skin is prone to breakdown, especially in immobile clients. Recalculating the Braden score is critical to adjust interventions, like skin protection or repositioning, to prevent ulcers, aligning with evidence-based wound care practices.

A. Maintain in high Fowler’s position. B. Report any change in urine color. C. Keep mucous membranes moist. D. Record the client’s daily weight.

Correct Answer is C

Explanation

Choice A reason: High Fowler’s position aids breathing in respiratory distress but is not universally indicated without context. It may strain the client’s back or increase fatigue if sustained. Keeping mucous membranes moist is a broader intervention, preventing complications like oral infections or discomfort, especially in dehydrated or oxygen-dependent clients, making it more appropriate.

Choice B reason: Reporting changes in urine color monitors renal or hydration status but is less immediate than maintaining mucous membranes. Dry membranes risk infection or discomfort, particularly in clients on oxygen or with reduced oral intake. Urine monitoring is secondary, as it reflects longer-term changes rather than addressing an urgent physiological need.

Choice C reason: Keeping mucous membranes moist prevents drying, which can lead to infections, discomfort, or impaired swallowing. This is critical for clients on oxygen, with reduced intake, or in dry environments. Moist membranes support airway protection and comfort, aligning with nursing priorities to maintain basic physiological functions and prevent complications.

Choice D reason: Recording daily weight tracks fluid status or nutritional changes but is less urgent than moist mucous membranes. Dry membranes pose immediate risks like infection or airway irritation, especially in vulnerable clients. Weight monitoring is a longitudinal assessment, secondary to addressing acute comfort and infection prevention needs.

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

After reviewing the admission assessment of a client, which intervention(s) should the nurse include in this client’s plan of care? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Correct Answer is D

Explanation

Which intervention should the nurse implement for a client?

Correct Answer is C

Explanation

The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

An older adult woman with end-stage heart disease is hospitalized for severe heart failure (HF). She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. Which action should the nurse take first?

A prescription for bilateral soft wrist restraints is obtained for an older adult client who has repeatedly removed the nasogastric tube (NGT) and IV sites. After applying the restraints, which action is most important for the nurse to take?

The nurse has agreed to serve as a client’s advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, which action is essential for the nurse to take?

After reviewing the admission assessment of a client, which intervention(s) should the nurse include in this client’s plan of care? (Select all that apply)

An unlicensed assistive personnel (UAP) is asked to answer the call light for a client with streptococcal pharyngitis for whom droplet precautions have been implemented. The UAP refuses, informing the nurse of not being fitted for an N95 respirator mask. Which action should the nurse take?

When identifying the goals to be included in a client’s plan of care, the nurse should take which action?

After an IV antibiotic is started, the nurse discovers that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?