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The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

An 82-year-old client with Alzheimer's disease and a newly fractured femur who has an indwelling urinary catheter and soft wrist restraints applied.

A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race.

A 34-year-old admitted today after an emergency appendectomy who has a PIV and indwelling urinary catheter.

A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline lock PIV.

Answer and Explanation

The Correct Answer is A

A. The combination of cognitive impairment, physical injury, and restraints poses a high risk for complications such as infection, skin breakdown, and falls. Close monitoring and nursing interventions are critical to ensure safety, comfort, and appropriate care in this patient.

B. While this client may need some care for the electrolyte imbalance and nausea, this situation is more stable compared to the elderly client with Alzheimer's. The RN's role here would focus on managing the electrolyte disturbance and providing symptom relief.

C. Although this client is postoperative and may need some care, the RN's focus would primarily be on pain management and monitoring for infection or complications. However, the client’s condition is relatively stable compared to the elderly client with multiple risks.

D. This client is also stable and may require some ongoing monitoring for respiratory issues. However, the level of care needed is less intensive compared to a client with cognitive issues, restraints, and a recent fracture.

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Correct Answer is D

Explanation

A. Abdominal cramping: Abdominal cramping can be a common symptom of gastritis and may not necessarily require immediate reporting unless it is severe or accompanied by other concerning symptoms.

B. Low grade fever: A low-grade fever can occur with gastritis as part of the inflammatory response, but it is not an immediate concern unless it persists or worsens. It is generally not as urgent as other symptoms.

C. Bruising of the skin: Bruising is not a typical symptom of gastritis. It may be indicative of a bleeding disorder or other underlying issues unrelated to the gastrointestinal system. However, it is not directly associated with gastritis.

D. Bloody emesis: Bloody emesis (vomiting blood) is a critical sign that indicates possible gastrointestinal bleeding, which can occur with severe gastritis. This is an emergency situation and should be reported immediately as it requires urgent medical attention.

A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting. B. Encourage family members to cook meals outdoors and bring the cooked food inside. C. Assess the client's mucous membranes and report the findings to the healthcare provider. D. Advise the client to replace cooked foods with a variety of different nutritional supplements.

Correct Answer is B

Explanation

A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting:While antiemetics can be helpful, this action may not address the underlying issue of food smells causing nausea. It is important to address the client’s sensory triggers.

B. Encourage family members to cook meals outdoors and bring the cooked food inside:
This can help reduce the trigger for nausea caused by the smell of cooking food. Cooking outdoors minimizes exposure to food smells, which could alleviate the client’s discomfort.

C. Assess the client's mucous membranes and report the findings to the healthcare provider: Assessing the mucous membranes is important in general care, especially for clients with cancer, but it is not directly related to the reported issue of nausea triggered by food smells.

D. Advise the client to replace cooked foods with a variety of different nutritional supplements: While nutritional supplements can be useful if the client is unable to tolerate solid foods, this advice doesn't address the root cause of the nausea related to food smells.

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The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

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Naxlex Comprehensive Predictor Exams

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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