The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Fluid volume deficit.

Caregiver role strain.

Bowel incontinence.

Impaired bed mobility.

Answer and Explanation

The Correct Answer is A

A.   Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B.   While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C.   This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D.   Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.

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Correct Answer is ["1.4"]

Explanation

To calculate the dosage of lorazepam for the client, first determine the total micrograms required by multiplying the client's weight in kilograms by the prescribed amount per kilogram. For a client weighing 65 kg prescribed 44 mcg/kg, the total dosage would be 65 kg x 44 mcg/kg, which equals 2860 mcg. Since the medication is available in a concentration of 2 mg/ml, convert the total dosage from micrograms to milligrams by dividing by 1000 (because there are 1000 micrograms in a milligram). This results in 2.86 mg. Finally, to find out how many milliliters to administer, divide the total milligrams needed by the concentration of the vial, which is 2 mg/ml. Therefore, 2.86 mg / 2 mg/ml equals 1.43 ml. When rounding to the nearest tenth, the nurse should administer 1.4 ml of lorazepam.

A. A peanut butter sandwich with soda and cookies. B. A salad with three kinds of lettuce and fruit. C. A tuna fish sandwich with chips and ice cream. D. Vegetable soup, crackers, and milk.

Correct Answer is C

Explanation

A. Peanut butter sandwich with soda and cookies is not a high-protein choice and contains excessive sugar and empty calories.
B. Salad with lettuce and fruit may not provide sufficient protein for wound healing.

C. A tuna fish sandwich is high in protein, which aligns with the goal of promoting wound healing.
D. Vegetable soup, crackers, and milk lack adequate protein content compared to a tuna fish sandwich.

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The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.4"]

Explanation

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

Correct Answer is C

Explanation

Exhibits Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one but may have more than response option selected

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