Patient Data
The nurse reviews the findings in the history and physical.
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The nurse recognizes that
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"C"}
Pressure injuries: These can indicate neglect or inadequate care, as they often develop from prolonged periods of immobility or poor hygiene.
Poor hygiene: A foul odor and unclean environment, along with a lack of clothing, can be signs of neglect or mistreatment.
Malnutrition: The client's low weight (98 lb or 44.5 kg) and a lack of appropriate nutrition could indicate inadequate care and potential mistreatment, contributing to overall poor health and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Increased urination due to IV fluids is common and not immediately concerning.
B. Comfort with an elevated head of bed is typical postoperatively.
C. A tight dressing could indicate swelling or a potential complication such as hematoma, which can compromise the airway and requires immediate assessment.
D. Dizziness upon standing is common and not as urgent as potential airway compromise.
Correct Answer is C
Explanation
A. Administering PRN oral analgesics can be managed by both RNs and PNs, as this task does not require advanced assessment or decision-making.
B. Transporting a client who is receiving IV fluids can be safely done by UAPs with appropriate supervision.
C. The RN is responsible for the supervision of other nursing staff and the orientation of new hires. Evaluating the competency of a graduate nurse during a complex task like an admission assessment cannot be delegated to a PN or UAP. An "admission assessment" is the initial comprehensive evaluation of a client. In most nursing jurisdictions, the initial assessment and the development of the nursing care plan are strictly the responsibility of the RN.
D. While the RN is responsible for the overall care plan of a restrained client, ongoing focused assessments (such as checking circulation, skin integrity, and pulse) for a client in restraints can often be delegated to a PN once the initial assessment and necessity for the restraint have been established by the RN.
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