Review the electronic health record. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated

Provide a high-fiber diet rich in fruits and vegetables

Reposition the client every 1-2 hours

Apply thromboembolic deterrent (TED) hose

Decrease fluid intake to less than 1500 mL a day

Complete all hygiene care for the client

Encourage the client to cough and deep breathe

Answer and Explanation

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

• Provide a high-fiber diet rich in fruits and vegetables: Post-operative clients, especially older adults, are at risk for constipation due to immobility and opioid pain medications. Offering a high-fiber diet promotes bowel regularity and prevents complications such as fecal impaction. Adequate nutrition also supports healing and energy levels during recovery.

• Reposition the client every 1-2 hours: Frequent repositioning reduces the risk of pressure injuries, particularly in immobile post-operative clients. It also promotes circulation and prevents discomfort. Early mobilization and turning are essential components of post-operative care to maintain skin integrity and prevent complications.

• Apply thromboembolic deterrent (TED) hose: Post-operative patients are at increased risk for venous thromboembolism due to immobility. TED hose improve venous return, reduce pooling of blood in the lower extremities, and prevent deep vein thrombosis. This intervention is a standard preventive measure after orthopedic surgery.

• Decrease fluid intake to less than 1500 mL a day: Restricting fluids in a post-operative client with low oxygen saturation (88% on room air) is contraindicated. Adequate hydration is necessary to maintain blood volume, support kidney function, and prevent complications. Limiting fluid intake could exacerbate hypotension, hypoxia, or dehydration.

• Complete all hygiene care for the client: Assisting with hygiene helps prevent skin breakdown, reduces infection risk, and promotes comfort. Maintaining cleanliness is crucial in post-operative recovery and supports overall health. This intervention is indicated for clients with limited mobility.

• Encourage the client to cough and deep breathe: After surgery, especially following immobility and anesthesia, clients are at risk for atelectasis and pneumonia. Encouraging deep breathing and coughing promotes lung expansion, enhances oxygenation, and clears secretions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Place a hat on the client's head: Covering the head helps reduce heat loss, but it does not immediately stop ongoing heat loss from wet clothing in hypothermia. Head covering alone is insufficient in acute exposure.

B. Remove wet clothes, replacing them with dry ones: Wet clothing increases conductive and evaporative heat loss, accelerating hypothermia. Removing wet garments and replacing them with dry, insulated clothing or blankets immediately prevents further body heat loss and stabilizes core temperature. This is the highest priority initial action.

C. Provide hot liquids once the client is conscious: Warm fluids can support rewarming but are only safe after the client is alert and able to swallow. This intervention is secondary to removing wet clothing and insulating the body.

D. Place a warming blanket over the client: Warming blankets are effective for rewarming but work best after wet clothing is removed. Placing a blanket over wet clothing may trap cold and slow rewarming.

A. A client who needs assistance ambulating in the hall B. A client with pain 4/10 requesting pain medication C. A client with a scheduled wound dressing change D. A client with a change in their level of consciousness

Correct Answer is D

Explanation

A. A client who needs assistance ambulating in the hall: Helping with ambulation is important to prevent falls, but it does not indicate an immediate threat to life or safety. This task can be delegated or scheduled after addressing higher-priority needs.

B. A client with pain 4/10 requesting pain medication: Moderate pain requires timely management to promote comfort, but it is not an urgent threat to physiologic stability. Pain management can follow assessment of clients with acute changes.

C. A client with a scheduled wound dressing change: Routine wound care is necessary for healing and infection prevention, but it is a planned intervention that does not indicate an urgent change in status. It can be scheduled after clients with acute concerns are addressed.

D. A client with a change in their level of consciousness: Altered mental status can indicate hypoxia, infection, intracranial pathology, or metabolic disturbance. This represents an immediate, potentially life-threatening change and requires rapid assessment and intervention.

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Review the electronic health record. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who fell through the ice while ice skating. To prevent further decrease in body temperature, which action should the nurse take first?

Correct Answer is B

Explanation

The nurse cares for a group of clients. Which client should the nurse prioritize?

Correct Answer is D

Explanation

The nurse is caring for a group of clients who all need bed alarms to prevent falls. Which client should the nurse ensure has the bed alarm enabled first?

The nurse delegates the positioning of an older client with immobility to unlicensed assistive personnel (UAP). Which action taken by the UAP requires the nurse to intervene?

The nurse plans care for a client with a wound positive for methicillin-resistant Staphylococcus aureus (MRSA). What action should the nurse include in the care of this client?

A nurse is assessing a client in high-Fowler's position for signs of skin breakdown. Which areas should the nurse assess first?

The nurse is caring for a client who is on airborne precautions. What action should the nurse take when using personal protective equipment (PPE)?

What is an example of a vector involved in disease transmission?

Complete the following sentence by choosing from the list of options. A pressure injury that presents with only dropdownis classified as a dropdownpressure injury.

The nurse is watching a new nurse ventilate a client using a bag-valve mask with capnography capabilities. The nurse notices that the client's PaCO2 level is 30 mm Hg. How should the nurse interpret this finding?