Exhibits

Review H and P and nurse's note.

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 two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

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

Explanation

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

A. Avoids adjusting the height of the hand grips. B. Holds the crutch 6 inches (15 cm) to the side. C. Fits the crutch 2 finger widths from axilla. D. Walks with the arms fully extended.

Correct Answer is C

Explanation

A. Adjusting the hand grips is necessary to ensure that the client can bear weight comfortably through the arms without placing stress on the wrists or shoulders, so avoiding this adjustment is incorrect.
B. Holding the crutch 6 inches to the side is a common guideline, but it is not as crucial as ensuring the correct fit of the crutches to avoid axillary nerve damage and ensure proper posture.
C. The crutch should fit 2 finger widths below the axilla to prevent pressure on the brachial plexus nerves, which can lead to nerve damage. This demonstrates an understanding of proper crutch fit and use.
D. Walking with the arms fully extended is incorrect; the arms should be slightly bent at the elbows to allow for proper weight distribution and movement.

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Naxlex Comprehensive Predictor Exams

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

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

Explanation

The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

Correct Answer is C

Explanation

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?