The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

Bowel incontinence.

Impaired bed mobility.

Caregiver role strain.

Fluid volume deficit.

Answer and Explanation

The Correct Answer is D

D. Addressing fluid volume deficit promptly is essential to prevent complications such as hypovolemic shock and renal dysfunction.

A. Bowel incontinence, especially in a client with celiac disease experiencing diarrhea, can lead to skin breakdown, discomfort, and embarrassment. However, it may not be the highest priority if the client's safety and physiological needs are not compromised.

B. Impaired bed mobility after knee replacement surgery can impact the client's recovery, comfort, and risk of complications such as deep vein thrombosis (DVT). However, if the client's condition allows for safe positioning and mobility within bed, this problem may not be the highest priority compared to more immediate concerns.

C. Caregiver role strain is a valid concern, especially if the primary caregiver is experiencing difficulty managing the client's needs. However, the priority is typically focused on addressing the client's immediate physiological needs before addressing caregiver concerns.

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Correct Answer is A

Explanation

A. Elevate the head of bed 45 degrees is the correct action because it helps clear the airway and reduce vomiting.

B. Irrigating the nasogastric tube with water is not the most appropriate action in this scenario. While it may help clear any obstructions in the tube itself, it does not directly address the immediate concern of clearing the airway of vomitus to prevent aspiration.

C. While suctioning is an effective intervention for clearing the airway, if the client is in a choking situation, establishing a safe position (like elevating the head of the bed) is a priority before any suctioning is performed.

D. Reviewing the advance directive document is important for understanding the client's wishes regarding medical interventions, including resuscitation and life-sustaining treatments.

A. Underline key words on the written information. B. Speak loudly and face the client. C. Use everyday language when explaining issues. D. Provide a very well-lit meeting space.

Correct Answer is C

Explanation

C. When providing health teaching to older adult clients, using everyday language is crucial. Older adults may have varying levels of health literacy and cognitive abilities, so using simple, clear language facilitates better understanding and comprehension of the information being provided.

A. Underlining key words on the written information may be helpful for emphasizing important points, but it is not as critical as using everyday language to enhance understanding

B. Speaking loudly and facing the client may not be necessary for all older adult clients and could even be perceived as patronizing or disrespectful.

D. Providing a very well-lit meeting space is important for optimizing visual acuity, especially for older adults who may have age-related changes in vision. However, while adequate lighting is beneficial, it is not as critical

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The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is A

Explanation

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Correct Answer is C

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

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The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

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