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 C

Explanation

A. The amount of fluid the client drank today: Although fluid intake affects weight, daily weights are intended to reflect overall fluid and nutritional changes over time, not just today's intake. Monitoring intake is important but not the most critical factor in conducting daily weights consistently.
B. When the client wants to be weighed: While respecting the client's preferences is important for cooperation, clinical accuracy requires consistency in timing and conditions, not simply weighing at the client's preferred time.
C. When the client was last weighed: Knowing when the client was last weighed ensures consistency and accuracy for monitoring trends. Daily weights should be taken at the same time each day, ideally in the morning before eating and after voiding, to accurately track fluid balance and body mass changes.
D. The amount of food the client ate today: Food intake affects weight slightly, but the purpose of daily weights is to detect significant changes, such as fluid retention or loss. Weighing under consistent conditions matters more than focusing on the day's food intake.

A. Require family members and visitors to wear a mask and gown when visiting the client. B. Have the client stay in a room separate from the family with the door closed. C. Use paper plates and disposable utensils for the client's meals and snacks.. D. Place soiled dressings in a plastic bag that can be tightly secured for disposal.

Correct Answer is D

Explanation

A. Require family members and visitors to wear a mask and gown when visiting the client: Masks and gowns are needed in healthcare settings to prevent cross-contamination, but at home, strict use of personal protective equipment (PPE) is not typically necessary for a draining wound unless there is high-risk exposure. Basic hygiene is usually sufficient.
B. Have the client stay in a room separate from the family with the door closed: Isolation at home is generally not necessary unless the infection is highly contagious through casual contact. Emphasis should instead be placed on good wound care and proper hygiene practices.
C. Use paper plates and disposable utensils for the client's meals and snacks: There is no need to use disposable eating utensils. Normal dishwashing practices are adequate to prevent the spread of infection in a home environment, as long as proper cleaning is maintained.
D. Place soiled dressings in a plastic bag that can be tightly secured for disposal: Proper disposal of contaminated dressings in a sealed plastic bag prevents leakage and minimizes exposure to infectious materials. This practice protects household members from accidental contact with wound drainage.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is implementing a nursing care plan that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

Correct Answer is C

Explanation

A male client who was treated for a draining, infected wound and placed on contact precautions while hospitalized is being discharged to his home where he lives with his wife and adolescent son. Which information should the practical nurse (PN) reinforce with the family?

Correct Answer is D

Explanation

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