Patient Data

Exhibits

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.

Instruct incentive spirometry use every hour.

Use petroleum based lotion on skin.

Administer antibiotics.

Suggest that client ambulate often.

Encourage consumption of protein and vitamin C.

Apply thromboembolism deterrent stockings (TED).

Answer and Explanation

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

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

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Correct Answer is A

Explanation

A. Pasta with fish and an orange: This is the best option because fish provides high-quality protein in moderation, pasta is low in potassium and phosphorus, and an orange provides vitamin C. While oranges contain potassium, a single serving can usually fit within dietary allowances if monitored.

B. Canned ham and green beans: Canned ham is high in sodium and phosphorus additives, both of which are harmful in CKD as they worsen fluid retention and bone-mineral imbalance.

C. Steak and baked potato with butter and cheese topping: Steak is a high-protein food that can increase uremic toxins, and baked potatoes are very high in potassium. The cheese topping adds extra phosphorus, making this meal unsafe for CKD clients.

D. Chicken, yams, pinto beans and pecans: While chicken is acceptable protein, yams and pinto beans are high in potassium, and pecans add excess phosphorus. This combination would increase the risk of electrolyte imbalance in CKD.

A. Offer to discuss the client's health status with each of the adult children. B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children. C. Gather information regarding how long it will take for the children to arrive. D. Explain that the client will start to lose consciousness and the body systems will slow down.

Correct Answer is D

Explanation

A. Offer to discuss the client's health status with each of the adult children: While involving family in discussions is important, the immediate question from the spouse is about recognizing signs of imminent death. Directly explaining the physiological changes is more appropriate at this moment.

B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children: Waiting for the HCP to give a signal does not provide the spouse with the knowledge they are seeking. It may delay preparation and increase anxiety during the final hours.

C. Gather information regarding how long it will take for the children to arrive: While logistical planning is helpful, it does not address the spouse’s question about recognizing imminent death and understanding what to expect.

D. Explain that the client will start to lose consciousness and the body systems will slow down: Providing clear, compassionate information about the expected signs of dying helps the spouse recognize that death is near, allows family members to prepare emotionally, and facilitates meaningful final interactions with the client.

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Patient Data Exhibits 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

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

Correct Answer is A

Explanation

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks, "How will I know that my husband's death is imminent? Our two adult children want to be here when their father dies." Which is the best response by the nurse?

Correct Answer is D

Explanation

Patient Data Exhibits Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?

A client's respiratory assessment reveals crackles, decreased tactile fremitus, and a dull sound in left lower chest during percussion. Which condition should the nurse document in the electronic medical record?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Patient Data

Exhibits

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.