Exhibits

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Check capillary refill on bilateral upper extremities.

Administer ondansetron 4 mg IV.

Inspect the bandage for drainage.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities. - Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV. - Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage. - Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

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Correct Answer is C

Explanation

Choice A rationale

While understanding risk factors for osteoporosis is important, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

Choice B rationale

While constipation due to immobility can be a concern for clients with osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

Choice C rationale

Identifying home safety hazards to be resolved immediately is the highest priority for an older adult client diagnosed with osteoporosis. Osteoporosis increases the risk of fractures, and falls are a common cause of fractures in older adults. Therefore, ensuring a safe environment is crucial.

Choice D rationale

While adding calcium-rich foods to the daily diet can help manage osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

A. The patient was able to sleep through the night. B. The patient’s left arm is warm to touch. C. The patient’s left shoulder and collarbone are symmetric. D. The patient has no desire to eat breakfast.

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

Explanation

Choice A rationale

The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.

Choice B rationale

The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.

Choice C rationale

The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.

Choice D rationale

The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.

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Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?

Correct Answer is C

Explanation

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

Explanation

When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

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The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest.Which action should the nurse take?

Exhibits

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.