Patient Data
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.
Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.
Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.
Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.
Correct Answer is ["A","C","G","H"]
Explanation
Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.
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