An older adult client who cares for her husband at home has just learned that she needs to have knee replacement surgery. She tells the nurse she is concerned about her inability to provide care to her husband while she recovers from surgery and attends physical therapy. She has a friend who can drive her to and from her appointments once she is discharged, but cannot provide the care her husband needs. How should the nurse respond to the client?

Tell her to consider hiring a private nurse during the postoperative convalescence.

Suggest contacting social services to help find a respite care facility for her husband.

Advise to have a case management evaluation of the client's home environment.

Recommend that the client's family return to the area to help provide assistance.

Answer and Explanation

The Correct Answer is B

A. Hiring a private nurse may be an option but is not the most immediate or practical solution given the client's current resources and concerns.

B. Suggesting contacting social services to find respite care is a practical and immediate solution to ensure her husband’s care while the client recovers.

C. A case management evaluation is helpful but may not address the immediate need for respite care during the client's recovery period.

D. Recommending that the family return might not be feasible or immediate, and respite care can provide the necessary support during recovery.

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Correct Answer is C

Explanation

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

A. Check femoral site for hematoma formation. B. Evaluate the integrity of the IV insertion site. C. Stimulate the client to take deep breaths. D. Assess distal lower extremity capillary refill.

Correct Answer is A

Explanation

A. Checking the femoral site for hematoma formation is crucial because pain at the groin insertion site could indicate bleeding or hematoma formation, which is a potential complication of cardiac catheterization.

B. Evaluating the IV insertion site is important but not as directly related to the groin pain as checking the femoral site.

C. Stimulating the client to take deep breaths is helpful for respiratory function but does not address the groin pain issue.

D. Assessing distal lower extremity capillary refill is important for overall circulation but is not the immediate priority in this scenario.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

The nurse is providing dietary education to a client in end stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?

Twelve hours after experiencing a traumatic closed fracture of the lower left tibia, a client reports pain, tingling, and diminished toe movement in the left foot. Which nursing problem has the highest priority based on this information?

Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

Patient Data Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Exhibits The nurse educates the client about living with benign prostate hyperplasia (BPH). Select the 3 areas of teaching that should be included when providing education to the client with symptomatic benign prostate hyperplasia.

An client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day intravenously in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)