An older adult man comes to the clinic with a painful rash over his left abdomen. He tells the nurse that he has tried a variety of creams and ointments, but none of them have relieved his symptoms. Which action is most important for the nurse to take?

Place a mask on the client until the cause of the rash is determined.

Determine if the pain was present before the cream was applied.

Question the client about recent exposure to sick children.

Use personal protective equipment while assessing rash.

Answer and Explanation

The Correct Answer is D

Choice A reason: Placing a mask on the client is unnecessary unless the rash is associated with a respiratory pathogen, which is unlikely for an abdominal rash. PPE, like gloves, is critical to protect the nurse from potential infectious causes, such as herpes zoster, ensuring safety during direct assessment of the rash.

Choice B reason: Determining if pain preceded cream application helps identify the rash’s cause but is not the first priority. Using PPE during assessment protects the nurse from infectious rashes, like herpes zoster, which is suggested by the painful, unilateral distribution. Safety during direct contact takes precedence over historical data collection.

Choice C reason: Questioning exposure to sick children may identify infectious causes like varicella but is secondary to nurse safety. A painful abdominal rash suggests herpes zoster, requiring PPE during assessment. Protecting the nurse from potential pathogens during physical examination is the immediate priority before gathering exposure history.

Choice D reason: Using PPE, such as gloves, is critical when assessing a painful abdominal rash, which may indicate herpes zoster, a contagious infection. PPE prevents nurse exposure to infectious agents during direct contact. This action ensures safety, aligning with infection control protocols, especially for unilateral, painful rashes suggestive of shingles.

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Correct Answer is B

Explanation

Choice A reason: Determining who brought the coffee is irrelevant to addressing the client’s dietary needs. A clear liquid diet includes black coffee, as it is transparent and easily digested. The priority is ensuring dietary compliance, not investigating staff actions, which does not impact the client’s immediate care or safety.

Choice B reason: Reminding the client that no milk or creamer can be added ensures adherence to a clear liquid diet, which includes black coffee. Coffee without additives is transparent and digestible, fitting dietary guidelines. This action educates the client, prevents dietary violations, and maintains the therapeutic purpose of the prescribed diet.

Choice C reason: Consulting the dietician is unnecessary, as black coffee is standard in clear liquid diets per nutritional guidelines. This action delays care and overcomplicates a straightforward issue. The nurse can directly clarify that coffee is allowed without additives, ensuring compliance without external consultation.

Choice D reason: Removing the coffee is incorrect, as black coffee is permitted in a clear liquid diet. This action unnecessarily restricts the client’s intake and may cause confusion or dissatisfaction. The nurse should instead educate the client about proper consumption, ensuring dietary adherence while maintaining patient comfort.

A. Implement a 24-hour schedule of routine administration of prescribed analgesic. B. Encourage increased fluid intake and measure urinary output every 8 hours. C. Assist the client to ambulate as much as possible during waking hours. D. Provide comfort measures such as topical warm application and tactile massage. E. Determine client’s subjective measure of pain using a numerical scale.

Correct Answer is ["B","C","D"]

Explanation

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.

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An older adult man comes to the clinic with a painful rash over his left abdomen. He tells the nurse that he has tried a variety of creams and ointments, but none of them have relieved his symptoms. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is B

Explanation

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)

Correct Answer is ["B","C","D"]

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?

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a 0 to 10 scale. After placing a call to the healthcare provider, which action should the nurse implement?

The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which description(s) warrant additional follow-up by the nurse? (Select all that apply)