The nurse identifies several nursing problems for an older adult client with gastroenteritis who is experiencing fever, chills, anorexia, and diarrhea.
The client has a history of a stroke with left-sided hemiplegia and is dependent on care provided by the spouse. Which problem should the nurse determine has the highest priority?

Fluid volume deficit.

Impaired bed mobility.

Caregiver role strain.

Bowel incontinence.

Answer and Explanation

The Correct Answer is A

Choice A rationale
In a client with gastroenteritis experiencing fever, chills, anorexia, and diarrhea, fluid volume deficit is a major concern. Diarrhea and fever can both lead to significant fluid loss. If not addressed, fluid volume deficit can lead to serious complications such as hypovolemic shock.
Choice B rationale
While impaired bed mobility may be a concern due to the client’s history of stroke, it is not the highest priority in this situation. The immediate physiological needs related to the client’s gastroenteritis and potential fluid volume deficit should be addressed first.
Choice C rationale
Caregiver role strain may be a concern given that the client is dependent on care provided by the spouse. However, this psychosocial issue is not the highest priority when the client is experiencing acute physical symptoms that need immediate attention.
Choice D rationale
Bowel incontinence could be a concern for a client with gastroenteritis. However, the risk of fluid volume deficit due to diarrhea and fever is a more immediate concern.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale

Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.

Choice B rationale

Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.

Choice C rationale

While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.

Choice D rationale

Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.

A. Offer the client oral fluids. B. Feed the client a snack. C. Assess the breath sounds. D. Empty the urinary drainage bag.

Correct Answer is D

Explanation

Choice A rationale
Offering the client oral fluids is important for hydration, but it may not be appropriate for all patients, especially those with certain medical conditions or those who are NPO (nothing by mouth)7.
Choice B rationale

Feeding the client a snack can help maintain energy levels, but it may not be appropriate for all patients, especially those with dietary restrictions or those who are NPO7.
Choice C rationale
Assessing breath sounds is an important part of respiratory assessment, but it is not typically within the scope of practice for unlicensed assistive personnel (UAP). This task should be performed by a licensed nurse.
Choice D rationale
Emptying the urinary drainage bag is an appropriate task for a UAP to perform each time the client is turned. This helps ensure accurate measurement of urinary output and prevents infection by keeping the bag below the level of the bladder.

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Naxlex Comprehensive Predictor Exams

An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

Correct Answer is A

Explanation

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to perform each time the client is turned?

Correct Answer is D

Explanation

When providing nursing care for a client after a gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?

An intravenous (IV) antibiotic is prescribed for a patient with a postoperative infection. The medication is to be administered in 4 divided doses. Which schedule is best for administering this prescription?

The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy. Which intervention is most important for the nurse to include in the patient’s plan of care?

A male adult is admitted due to an overdose of acetaminophen. After being transferred to the mental health unit, the patient is informed that he has liver damage. What is the most crucial information for the nurse to include in the patient’s discharge plan?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

What action should the school nurse take to provide secondary prevention for school-aged children?