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.

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Correct Answer is A

Explanation

A. When using a tympanic thermometer on an adult client, the correct technique involves pulling the auricle up and back to straighten the ear canal, which the UAP is doing correctly.

B. Tympanic thermometers typically only require a few seconds to obtain a temperature reading, not three minutes. Advising the UAP to hold the thermometer in place for three minutes would be incorrect and unnecessary.

C.This technique is used for children under three years old, not adults.
D. Lubricating the tympanic thermometer before insertion is not typically necessary, as most tympanic thermometers are designed to be used without lubrication.

A. Apply wrist restraints to prevent wandering. B. Leave the door to the client's room open slightly. C. Provide a back rub at bedtime. D. Administer a PRN sedative prescription.

Correct Answer is B

Explanation

A. Restraints should only be used as a last resort when all other options have been exhausted and there is an immediate risk to the safety of the client or others.
B. This option promotes safety by allowing for easier monitoring of the client while also preventing them from feeling completely confined. It can reduce anxiety and promote a sense of autonomy. It is a less restrictive approach than using restraints.

C.A back rub can be a soothing and calming intervention that may help the client relax and potentially improve sleep quality. However, while this is a good comfort measure, it does not directly address the immediate concern of wandering and confusion.
D. Administering sedatives should be approached cautiously, especially in older adults, due to the increased risk of adverse effects such as confusion, falls, and respiratory depression.

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Naxlex Comprehensive Predictor Exams

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

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?

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?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

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

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

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?