An older female client who resides at an assisted living facility comes for an annual gynecological visit at the clinic and states she has a burning sensation when urinating. Assessment findings include: blood pressure 128/88 mm Hg, urine negative for bacteria, and ecchymotic areas on both forearms. She reports being sexually active and drinks beer once or twice a month. During this clinic visit, which intervention(s) should the nurse implement? Select all that apply.

Ask the client if someone brought her to the clinic.

Review list of daily medications for aspirin or other anticoagulants.

Question her if she previously or currently uses of any illicit drugs.

Inquire if she is being emotionally or physically abused.

Determine number of sexual partners she has had recently.

Answer and Explanation

Correct Answer : B,D,E

Rationale:

A. Ask the client if someone brought her to the clinic: This may be useful in a general assessment but is not directly relevant to the client's urinary symptoms, bruising, or potential abuse concerns. It does not guide immediate care.

B. Review list of daily medications for aspirin or other anticoagulants: Ecchymoses may indicate increased bleeding risk, especially in older adults on aspirin or anticoagulants. Reviewing medications helps determine if bruising is medication-related or from trauma.

C. Question her if she previously or currently uses any illicit drugs: There’s no clinical indicator pointing toward drug use. This line of questioning may be inappropriate or unnecessary unless other findings support it.

D. Inquire if she is being emotionally or physically abused: Unexplained bruising, especially in older adults, can signal possible abuse. The nurse should screen for abuse sensitively and privately.

E. Determine number of sexual partners she has had recently: Given her report of sexual activity and urinary burning, assessing recent sexual history helps guide further STI screening and urinary symptom evaluation.

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Correct Answer is C

Explanation

Rationale:

A. Assess for fatty yellow streaks in the client's stool: This suggests steatorrhea, commonly linked to malabsorption syndromes—not relevant to recent thrombolytic use or bleeding risk.

B. Obtain a specimen for culture and sensitivity analysis: This is used to identify infectious organisms in cases of suspected gastrointestinal infection, not bleeding, which is the primary concern post-thrombolytic therapy.

C. Send a stool sample to the lab for a guaiac test: A guaiac test detects occult (hidden) blood in stool, which is essential for identifying gastrointestinal bleeding—a major complication of thrombolytic therapy.

D. Observe the stool for a clay-colored appearance: Clay-colored stool may indicate biliary obstruction or liver dysfunction, not a bleeding issue, which is the critical concern after thrombolytic administration.

A. Before changing assignments, determine which staff members have fitted particulate filter masks. B. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client. C. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care. D. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.

Correct Answer is B

Explanation

Rationale:

A. Before changing assignments, determine which staff members have fitted particulate filter masks: This option suggests rearranging assignments based on respirator fit, but a particulate filter mask (like an N95) is not required for droplet precautions. The focus should be on educating the UAP rather than altering assignments unnecessarily.

B. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client: Droplet precautions require a standard surgical mask, not a particulate filter mask. The nurse should clarify this with the UAP to ensure proper precautions are followed without unnecessary changes or delays in care.

C. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care: This adds unnecessary steps. For droplet precautions, a surgical mask is sufficient for all aspects of client care. There's no need to delay care or obtain a filter mask fitting.

D. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client: This is not necessary for droplet precautions, as it reflects confusion with airborne precautions (e.g., for tuberculosis). The nurse should correct the misunderstanding rather than escalate it.

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Naxlex Comprehensive Predictor Exams

A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement?

Correct Answer is C

Explanation

The nurse assigns an unlicensed assistive personnel (UAP) to a client who has been placed on droplet precautions for a respiratory infection. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer is B

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement?

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?

The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

The camp nurse is teaching adolescents about the prevention of tinea pedis. Which instruction should the nurse include in the teaching plan?

After diagnosis and initial treatment of a pre-school age child with cystic fibrosis, the nurse provides home care instructions to the parents. Which statement by the child's parents indicates that understanding of the home care treatment to promote pulmonary function?