An older adult client arrives to the emergency department after experiencing two days of fever, nausea, and vomiting. The client gives the nurse a bag of home medications and reports a history of insulin dependent diabetes mellitus with an onset of blurred vision. Which intervention should the nurse implement first?

Establish mental status baseline.

Insert an indwelling urinary catheter.

Check the accuracy of medication list.

Obtain a capillary blood glucose level.

Answer and Explanation

The Correct Answer is D

A.   While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B.   Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C.   Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D.   Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

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Correct Answer is B

Explanation

A. Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B. Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C. Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D. Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

A. Over the cheeks. B. Around the nostrils. C. Across the forehead. D. Bridge of the nose. E. Tops of the ears.

Correct Answer is ["A","B","D","E"]

Explanation

A. The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B. The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C. The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D. The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E. The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Correct Answer is B

Explanation

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?