Patient Data

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Encourage consumption of protein and vitamin C.

Apply thromboembolism deterrent stockings (TED).

Suggest that client ambulate often.

Administer antibiotics.

Use petroleum based lotion on skin.

Instruct incentive spirometry use every hour.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Rationale:

• Administer antibiotics: The client presents with left lower leg erythema, warmth, swelling, and a recent skin break, consistent with cellulitis. The presence of elevated WBC count (14.7 x 10⁹/L) supports an infectious process. Early administration of cefazolin IV is indicated to treat the bacterial infection and prevent progression to systemic infection or sepsis.

• Encourage consumption of protein and vitamin C: Adequate nutrition, including protein and vitamin C, supports wound healing and immune function. The client has a small scab and ongoing infection; protein is necessary for tissue repair, and vitamin C contributes to collagen synthesis and immune response. Supporting nutrition enhances recovery from cellulitis.

• Instruct incentive spirometry use every hour: Incentive spirometry is primarily indicated for clients at risk for pulmonary complications, particularly after surgery or with immobility. This client has no current pulmonary compromise or respiratory risk beyond baseline, so frequent incentive spirometry is nonessential.

• Use petroleum based lotion on skin: Petroleum-based lotion may increase skin moisture and maceration, particularly in an area of infection, which can worsen bacterial proliferation. Applying such products to an inflamed or broken area is contraindicated. Skin integrity must be protected without creating an environment favorable to infection.

• Suggest that client ambulate often: Frequent ambulation is contraindicated in the acute phase of cellulitis with leg swelling and pain. Increased movement may exacerbate edema, pain, or tissue injury. Bedrest or limited activity until infection stabilizes reduces the risk of complications such as cellulitis spread or ulceration.

• Apply thromboembolism deterrent stockings (TED): TED stockings are contraindicated in this client because applying compression over an acutely infected, edematous lower extremity can worsen tissue perfusion and increase discomfort. Compression should be avoided in infected or inflamed limbs until infection resolves. Applying TEDs could exacerbate local edema and pain.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Rationale:

• Red spots with bluish center: These lesions represent Koplik spots, which are a classic early finding seen on the buccal mucosa in measles. They appear before the widespread rash and are considered highly specific for this viral infection. Their presence helps distinguish measles from other childhood exanthems.

• Tachycardia: Tachycardia in this child is most likely a physiological response to fever rather than a disease-specific indicator. Many pediatric infections can cause elevated heart rate, making it nonspecific. It does not help differentiate between measles, rubella, or chicken pox. Therefore, it is not the most meaningful symptom for identifying the cause.

• Maculopapular rash: A maculopapular rash can be seen in both measles and rubella, making it less specific for a single diagnosis. Without additional distinguishing features, this rash pattern alone cannot confirm measles. The rash distribution is helpful but not diagnostic on its own. More specific signs are needed for accurate identification.

• Measles: Measles commonly presents with high fever, cough, anorexia, and a maculopapular rash that begins on the face and spreads downward. The presence of Koplik spots is a key diagnostic clue unique to measles. The child’s elevated temperature and respiratory symptoms further support this condition.

• Chicken pox: Chicken pox is characterized by vesicular lesions in different stages of healing rather than a maculopapular rash. It does not cause Koplik spots in the mouth. Respiratory symptoms such as cough are also less prominent. These differences make chicken pox an unlikely cause in this case.

• Rubella: Rubella can cause a maculopapular rash and mild fever but is typically associated with milder symptoms overall. Koplik spots are not seen in rubella. Respiratory symptoms like cough are less common and less severe. The presence of bluish-white oral lesions rules out rubella.

Correct Answer is ["200"]

Explanation

Calculation:

Identify the total volume and infusion time

Total Volume: 100 mL

Infusion Time: 30 minutes (0.5 hour)

Calculate the infusion rate

Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)

Infusion Rate = 100 ÷ 0.5

Infusion Rate = 200 mL/hr

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Patient Data For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Based on the client's symptoms, the nurse is considering what might be causing them. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse determines that the symptom of dropdown indicates dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

Correct Answer is ["200"]

Explanation

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment because the UAP has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Patient Data Based on the client’s assessment findings at 1800, which of the following findings require immediate nursing intervention prior to transfer to the intermediate care unit? Select all that apply.

When preparing to measure urinary output from a client's ileal conduit, which item(s) should the nurse bring to the room? Select all that apply.

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Patient Data

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.