Patient Data

Exhibits

Review was done of H and P, nurses' notes, and orders.

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 []

Pressure sores are divided into different stages:

Stage 1= Intact skin with non-blanchable redness over a localized area

Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base

Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed

Stage 4- Full thickness wound with exposed tendons, muscle and bone

Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue

The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.

Nutritional status determines the risk of developing pressure injury and the chances of wound healing.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. This response is compassionate and invites the client to share their feelings. The gentle touch on the forearm can convey empathy and support, but it’s important to ensure that physical contact is appropriate for the client. This option encourages open communication while respecting the client’s feelings.

B.While this response acknowledges the client's distress, it also dismisses their feelings by suggesting that the assessment can be postponed. This can make the client feel invalidated or that their emotions are not important enough to address immediately.
C. This offers physical comfort and reassurance, but again, the nurse must be mindful of the client's boundaries and preferences regarding physical contact.
D. Recognizes the client's distress and offers to return later, which might be appropriate if the client prefers to be alone. However, this option fails to offer an opportunity for support to the client.

A. Insert a rectal tube at specified intervals. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Encourage the use of incontinence briefs.

Correct Answer is B

Explanation

B. Assisting the client to a bedside commode after meals can help take advantage of the gastrocolic reflex, which typically stimulates bowel movements after eating. This timing may increase the likelihood of successful bowel evacuation and decrease the risk of soiling the bed and clothing.
A. Rectal tubes are sometimes used for bowel management in individuals with chronic fecal incontinence, but they are typically reserved for specific situations and are not commonly used as part of a routine bowel training regimen.
C. Glycerin suppositories are sometimes used to stimulate bowel movements in individuals with constipation, but they are not typically recommended as a routine intervention for managing fecal incontinence.
D. Incontinence briefs can help contain fecal soiling and minimize embarrassment associated with accidents but they do not address the underlying issues contributing to fecal incontinence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is A

Explanation

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client's plan of care? Select all that apply.

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication mg/mL vial. Which action should the nurse perform with the remainder of the medication?

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate. the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?