Exhibits

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Instruct incentive spirometry use every hour.

Encourage consumption of protein and vitamin C.

Apply thromboembolism deterrent stockings (TED).

Use Petroleum based lotion on legs

Answer and Explanation

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

Instruct incentive spirometry use every hour (Nonessential): There is no indication of respiratory compromise, so incentive spirometry is not a priority for this client.

Encourage consumption of protein and vitamin C (Indicated): These nutrients support wound healing and immune function, which are important in managing infection and preventing further complications.

Apply thromboembolism deterrent stockings (TED) (Contraindicated): TED stockings may worsen symptoms if the client has cellulitis or a deep vein thrombosis (DVT), as compression can increase pain and impede circulation in an already swollen and inflamed limb.

Use petroleum-based lotion on legs (Contraindicated): Petroleum-based products can trap moisture and create an environment for bacterial growth, which is not suitable for a client with cellulitis or diabetes. Instead, a diabetic-safe moisturizer should be used while avoiding open wounds.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Continues to take a prescribed vitamin D supplement. Vitamin D supplementation is recommended for older adults to support bone health and calcium absorption. This does not require additional follow-up.
B. Usually eats an additional serving of protein-rich foods daily. Adequate protein intake is essential for muscle maintenance and overall health in older adults. This is a positive nutritional habit and does not indicate a concern.
C. Takes 1200 mg of an over-the-counter calcium supplement daily. This is within the recommended daily intake for older adults (1,000-1,200 mg/day) to maintain bone health. Excess calcium intake should be monitored, but this amount alone does not require urgent follow-up.
D. Ate approximately 1,200 calories daily for the past two weeks. Older adults typically need at least 1,500-2,000 calories per day, depending on activity level and health conditions. A prolonged intake of only 1,200 calories per day may indicate malnutrition, unintentional weight loss, or inadequate nutrient intake, requiring further evaluation.

A. Body mass index greater than 35 kg/m2. B. Daily caloric intake of 3,500 calories. C. Client's expressed desire to lose 50 lb (22.7 kg). D. Body weight 10% over ideal body weight.

Correct Answer is A

Explanation

A. Body mass index greater than 35 kg/m². A BMI of ≥35 kg/m² indicates severe obesity and significantly increases the risk of chronic diseases such as hypertension, diabetes, and cardiovascular disease. Clients with a BMI ≥35, especially with comorbidities, should be referred for obesity counseling, lifestyle modifications, and possibly medical or surgical interventions.
B. Daily caloric intake of 3,500 calories. While consuming 3,500 calories daily may contribute to weight gain, caloric intake alone is not the primary indicator for an obesity counseling referral. BMI provides a more standardized measure of obesity risk.
C. Client's expressed desire to lose 50 lb (22.7 kg). A client’s motivation is important, but referral criteria for obesity counseling are based on clinical indicators like BMI rather than weight loss goals alone.
D. Body weight 10% over ideal body weight. Being 10% over ideal body weight does not necessarily indicate obesity. Obesity is typically defined as a BMI ≥30 kg/m², so this alone would not automatically warrant an obesity counseling referral.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is visiting an older adult client who is homebound. Which finding about the client's nutritional status requires additional follow- up?

Correct Answer is D

Explanation

Which information is most important for the nurse to consider in determining a client's need for an obesity counseling referral? Reference Range: Body mass index (BMI) [18.0 kg/m2 to 24.9 kg/m

Correct Answer is A

Explanation

A female client was horseback riding when her horse slipped and fell on her leg, crushing but not breaking it, and resulting in a large amount of edema over the crushed area. Which pathophysiological mechanism is responsible for the edema?

Which assessment finding of an older adult client should the nurse associate with normal aging?

A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. Which is the greatest clinical risk related to this situation?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and to parameters the nurse should monitor to assess the client's progress.

An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

Exhibits The nurse reviews the client's data. Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.

The nurse is caring for a one-month-old infant admitted for suspected congenital hypothyroidism. Which diagnostic test results should the nurse report to the healthcare provider?

Exhibits

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.