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At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

An adult client who has a history of sleep apnea and needs help applying a continuous positive airway pressure (CPAP) before bedtime.

The parent of a child who reports the child cannot sleep because there is too much noise in the hallway.

An older adult client recently admitted from a long-term care facility who is exhibiting sundowning behaviors.

An older adult client who is anxious about an impending procedure and is worried about being unable to sleep.

Answer and Explanation

The Correct Answer is A

A.   Sleep apnea is a serious condition where the airway becomes blocked during sleep, which can lead to significant health issues, including heart problems and severe oxygen desaturation. The CPAP machine is crucial for managing sleep apnea by ensuring continuous airflow during sleep. If this client needs help applying the CPAP and does not get the assistance they need, they may experience severe complications from untreated sleep apnea.
B.   While noise in the hallway can certainly disrupt a child’s sleep and cause distress, it is not an immediate health crisis. It is important to address environmental concerns for comfort and sleep quality but this situation is less critical compared to the potential health risks associated with untreated sleep apnea.
C. Sundowning refers to increased confusion and agitation in the late afternoon or evening, which can be distressing and challenging to manage. While important, this issue is generally not as immediately life-threatening as problems related to sleep apnea or severe anxiety about a procedure.
D.   Anxiety about an upcoming procedure and difficulty sleeping are significant concerns, especially for emotional and mental well-being. However, while this client’s anxiety should be addressed to improve their comfort and preparation for the procedure, it does not present an immediate physical threat to health like the potential complications of untreated sleep apnea.

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Correct Answer is C

Explanation

A. While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B. Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C. The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D. This is not relevant to the client's current symptoms of severe pain and nausea.

A. Presence of rebound phenomenon. B. Limitations to range of motion. C. Muscle strength and tone. D. Degree of neurosensory impairment.

Correct Answer is A

Explanation

A. This is a condition where the skin becomes hyperemic and hot after the application of heat. It's a sign of tissue damage and can lead to burns. Assessing for rebound phenomenon before applying a heating pad is crucial to prevent further injury.
B. While assessing range of motion can be helpful in determining the effectiveness of heat therapy, it's not the most important factor to consider before application.
C. Muscle strength and tone are not directly related to the risk of skin damage from heat therapy.
D. While neurosensory impairment can affect a client's ability to perceive heat and respond to pain, assessing for rebound phenomenon is a more direct way to evaluate the risk of skin damage.

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At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is A

Explanation

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

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?

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

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?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

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, what action is essential for the nurse to take?