Patient Data

Exhibits

The nurse reviews the client’s data.

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 []

Choice A reason:

There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.

Choice B reason:

The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.

Choice C reason:

There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.

Choice D reason:

Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.

Choice E reason:

An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.

Condition F reason:

The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.

Condition G reason:

There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:

Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.

Condition I reason:

There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.

Parameter J reason:

Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.

Parameter K reason:

While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.

Parameter L reason:

Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.

Parameter M reason:

Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.

Parameter N reason:

Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.

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Correct Answer is D

Explanation

Choice A reason: Printing the EMR from a backup server does not resolve the immediate issue of the system lockup and may not be possible if the system is down.

Choice B reason: Identifying information as a late entry is a step to take after the system issue has been resolved and does not address the current problem.

Choice C reason: Waiting for the system to be rebooted is passive and does not actively contribute to resolving the system lockup.

Choice D reason: Notifying the information services department is the first and most proactive step to take, as they are responsible for resolving technical issues with the EMR system.

A. Serum potassium: 3.5 mEq/L (3.5 mmol/L), serum sodium: 142 mEq/L (142 mmol/L) B. Serum potassium: 4.5 mEq/L (4.5 mmol/L), serum sodium: 140 mEq/L (140 mmol/L) C. Serum potassium: 5.0 mEq/L (5.0 mmol/L), serum sodium: 138 mEq/L (138 mmol/L) D. Serum potassium: 3.0 mEq/L (3.0 mmol/L), serum sodium: 149 mEq/L (149 mmol/L)

Correct Answer is A

Explanation

Choice A reason: The results are within the normal reference range for both potassium and sodium, which is expected unless the client's condition has led to significant electrolyte imbalances.

Choice B reason: A serum potassium level of 4.5 mEq/L is at the higher end of the normal range, which might not be expected in a client with vomiting and diarrhea, conditions that often lead to lower potassium levels.

Choice C reason: A serum potassium level of 5.0 mEq/L is at the upper limit of the normal range and could indicate hyperkalemia, especially in the context of severe dehydration.

Choice D reason: A serum sodium level of 149 mEq/L is slightly above the normal range and could indicate hypernatremia, which may occur in dehydration but would require further assessment and intervention.

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Naxlex Comprehensive Predictor Exams

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?