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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","E"]

Explanation

A. Drink between 8 to 10 cups (1.9 to 2.4 liters) of fluids daily: Staying hydrated is important, especially for a pregnant woman with gestational diabetes. Adequate fluid intake helps manage blood glucose levels and prevents dehydration.

B. Eliminate the bedtime snack if heartburn develops after eating: While heartburn is a common issue during pregnancy, it’s not specifically related to gestational diabetes. Instead of eliminating the bedtime snack, the client could be advised to choose lighter, non-acidic snacks.

C. Choose complex carbohydrates that are high in fiber content: Complex carbohydrates, such as whole grains, legumes, and vegetables, have a lower glycemic index compared to refined carbs. They are digested more slowly and help regulate blood sugar levels.

D. Increase the percentage of protein in the diet if anemia develops: If anemia develops, increasing iron-rich foods (not just protein) is essential. Iron-rich foods like leafy greens, red meat, and legumes should be emphasized, as protein alone may not address iron deficiencies.

E. Avoid foods high in refined sugars: Refined sugars cause rapid spikes in blood glucose levels, which can worsen gestational diabetes. It's important to limit these foods to help maintain stable blood sugar levels.

A. Iron-rich meats. B. Water and herbal teas. C. Low fat dairy products. D. Fresh fruits and vegetables.

Correct Answer is C

Explanation

A. Iron-rich meats: While iron is essential for preventing anemia, it does not contribute significantly to bone mineral density. These foods are not a primary recommendation for osteoporosis prevention, which focuses on calcium and vitamin D intake.

B. Water and herbal teas: Adequate hydration is important for overall health, but water and herbal teas do not contain the calcium or vitamin D needed to support bone health. They have minimal direct impact on preventing osteoporosis.

C. Low fat dairy products: Low fat dairy products like milk, yogurt, and cheese are rich in calcium and often fortified with vitamin D—both critical nutrients for maintaining bone density and preventing osteoporosis.

D. Fresh fruits and vegetables: Fruits and vegetables provide general nutritional support, but are not the most concentrated sources of bone-building nutrients like calcium. They support health broadly but are not the key dietary focus for osteoporosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The client asks the diabetic nurse educator to clarify what the Registered Dietician told her about the content and timing of her meals. Which 3 responses should the diabetic nurse educator provide?

Correct Answer is ["A","C","E"]

Explanation

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Correct Answer is C

Explanation

An older adult client is preparing for discharge following a myocardial infarction (MI). The nurse is reviewing the prescribed cardiac diet and exercise instructions with the client. Which action should the nurse implement while teaching?

A female client with aphasia is trying to verbalize feelings to the nurse and states, "I want...," but does not finish the statement. How should the nurse respond to this unfinished statement?

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Exhibits The nurse is preparing the client's plan of care. A major component of the clients at home care is pain management. Select the 3 most important interventions the nurse can educate the client with rheumatoid arthritis (RA) about to help with pain management.

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

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