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 C

Explanation

C. When the computer documentation system freezes, the first action the nurse should take is to notify the information services department of the situation. This allows the IT professionals to address the issue promptly and work on resolving the problem with the computer system.

A. Waiting for the system to reboot may lead to delays in documenting important patient information and could potentially affect the continuity of care. It's important to address the situation promptly to minimize any disruptions in patient care.

B. If the documentation system is unavailable for an extended period, identifying information as a late entry may be necessary to ensure that it is accurately recorded in the patient's record.

However, this should not be the first action taken, as there may be other immediate steps to address the situation.

D. While having a backup EMR is essential, printing it may not be the immediate solution. The focus should be on resolving the system freeze rather than relying solely on a printed backup.

Correct Answer is ["1"]

Explanation

1 gram= 1000mg
0.2 grams = 200 milligrams

Since each tablet is 200 mg, the nurse should administer:

200 mg ÷ 200 mg/tablet = 1 tablet

Therefore, the nurse should administer 1 tablet of allopurinol.

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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

The nurse is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

Correct Answer is C

Explanation

The healthcare provider prescribes allopurinol 0.2 grams PO for a client with gout. The available medication is labeled, "Allopurinol tablets 200 mg." How many tablets should the nurse administer? (Enter numerical value only, rounded to the nearest whole number.)

Correct Answer is ["1"]

Explanation

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

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