Exhibits

Review H and P, nurse's notes, laboratory results, and prescriptions.

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

Answer and Explanation

The Correct Answer is []

Protein deficiency: The client is post-operative (POD 4) and unable to tolerate solid foods, yet she is drinking full liquids without issue. This dietary limitation, especially after surgery, may not be providing sufficient protein, which is essential for wound healing and overall recovery. The client has a slow-healing surgical wound that is red around the edges with serosanguinous drainage. Protein deficiency can impair the body's ability to heal wounds properly and fight infections.
Include protein supplement shakes in the client's diet: These shakes can provide the necessary protein without requiring the client to eat solid food, ensuring she gets adequate nutrition to support healing and immune function. Protein is critical in recovery, particularly for wound healing and tissue repair, which is why this intervention is essential.
Advance diet to regular as tolerated: Once the client is able to tolerate liquids without issue, gradually introducing solid foods will ensure she receives a full spectrum of nutrients, including protein, from different food sources. This will support her overall nutritional needs and help improve the rate of wound healing. This should be done gradually, depending on how well the client tolerates solid food.
Signs of infection: The client has a surgical wound that is red around the edges and has serosanguinous drainage, which could indicate a potential infection. Given the risk of infection, especially in a slow-healing wound, monitoring for other signs such as increased redness, warmth, or purulent drainage is important.
Wound healing: Wound healing is a critical parameter to monitor in this patient. Given the client's slow-healing surgical wound and potential for protein deficiency, it’s important to track the progress of healing over time. Delayed healing could signal inadequate nutrition (like protein deficiency) or infection, so regular assessment of the wound will help guide further interventions.
Iodine deficiency: Iodine deficiency typically affects thyroid function and does not directly contribute to the wound healing problems or the inability to tolerate solid foods seen in this client. There are no signs in the patient's data that suggest thyroid dysfunction or iodine deficiency, making this an unlikely condition.
Glucose deficiency: While glucose is essential for energy, there is no indication from the client’s current condition or lab values that glucose deficiency is a concern. The client is awake and alert, and there are no signs of hypoglycemia or low blood sugar. The primary issue seems to be a lack of protein, not glucose.
Sodium deficiency: Sodium deficiency is unlikely because there are no signs of hyponatremia (like confusion, dizziness, or muscle cramps) or fluid imbalance, which would be expected in sodium deficiency. The client does not exhibit signs of hypovolemia, and her laboratory results do not suggest significant sodium imbalances.
Add table salt to any broth that the client takes: Adding salt is not necessary at this time because the client's sodium levels are not critically low. Sodium supplementation is typically used in cases of hyponatremia or fluid imbalances, which do not appear to be a concern here. The primary focus should be on addressing the protein deficiency.
Place a feeding tube and start enteral feeds: A feeding tube and enteral feeding are typically reserved for clients who are unable to tolerate any oral intake at all. Since the client is drinking full liquids, it is not necessary to place a feeding tube at this stage. If the client continues to struggle with solid food intake over time, then enteral feeding might be considered, but this is not immediately required based on the information provided.

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

Explanation

A. Show acceptance of the client's current feelings: Accepting the client’s emotional response without judgment builds trust and provides emotional support, which is critical when coping with a new diagnosis of advanced cancer.
B. Share a similar personal experience: Sharing personal experiences shifts the focus away from the client’s feelings and can be perceived as minimizing their unique emotional response. It is more therapeutic to focus entirely on the client’s experience.
C. Document the behavior in the client's record: Accurate documentation of the client's emotional state ensures continuity of care and alerts other healthcare providers to the client's need for emotional support and potential interventions.
D. Ask the palliative care nurse to see the client: Involving a palliative care specialist provides expert emotional, spiritual, and symptom management support, which is appropriate for a client newly diagnosed with stage IV cancer.
E. Allow the client a time to continue crying: Allowing the client to cry acknowledges their need to express grief and emotion. It helps the client begin processing the overwhelming news and supports healthy emotional expression.

A. A liquid nutritional supplement that contains protein. B. Beef broth, or chicken broth. C. Fortified lowfat milk. D. Apple or grapefruit juice.

Correct Answer is A

Explanation

A. A liquid nutritional supplement that contains protein: A full liquid nutritional supplement with added protein is best because protein is critical for skin integrity and tissue repair. Supplements also provide balanced calories, vitamins, and minerals necessary to support overall skin health and prevent breakdown.
B. Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.
C. Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.
D. Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.

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Naxlex Comprehensive Predictor Exams

A client who is recently diagnosed with stage IV ovarian cancer tells the practical nurse (PN) that the staff on the unit are insensitive and begins to cry. Which intervention(s) should the PN implement? Select all that apply.

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

Explanation

A client on a prescribed full liquid diet has a nursing problem of, "Risk for impaired skin integrity related to reduced oral intake." Which snack would be best to provide this client?

Correct Answer is A

Explanation

While providing oral care for a client who is unconscious, the practical nurse (PN) positions the client laterally and uses a basin to collect secretions. Which intervention is best for the PN to implement?

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While turning and positioning a bedfast client, the practical nurse (PN) observes that the client is dyspneic. Which action should the PN take first?

The practical nurse (PN) is caring for a client with influenza. Which action should the PN implement to prevent the spread of influenza?

To reduce a client's risk for footdrop, which action should the practical nurse (PN) implement?

An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?

The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned?