The nurse is reassessing a 57-year-old female client who was admitted to the hospital with a left upper arm open wound infection (methicillin-resistant Staphylococcus aureus [MRSA] and several gram-negative bacteria) and cellulitis 5 days ago.

Tomorrow she is scheduled for discharge to home with her daughter to continue oral antibiotic therapy for another 10 days.

For each assessment finding, use the choices from the drop-down box to indicate whether the interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).

Client reports mild pain in upper left arm at 2/10 on a scale of 0 to 10.

Client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L).

Client’s left upper arm slightly reddened when compared with right upper arm.

Client reports that her back is more achy since she came to the hospital.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The client reports mild pain in the upper left arm at 2/10 on a scale of 0 to 10. This indicates that the interventions were effective in managing the pain associated with the infection and cellulitis.
Choice B rationale
The client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L). This is within the normal range, indicating that the interventions were effective in maintaining the client’s blood glucose levels within the normal range.
Choice C rationale
The client’s left upper arm is slightly reddened when compared with the right upper arm. This could be a sign of inflammation or infection, suggesting that the interventions were ineffective in completely resolving the infection and cellulitis.
Choice D rationale
The client reports that her back is more achy since she came to the hospital. This could be due to a variety of factors, including the hospital bed or a lack of physical activity. It is unrelated to the expected outcomes of the interventions for the infection and cellulitis.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale
Using white out to remove incorrect documentation and writing the correct information over the white out is not an acceptable practice according to CMS guidelines. This method does not allow for the original documentation to be seen, which is a requirement for making corrections to documentation.
Choice B rationale
Using a permanent marker to eliminate all incorrect documentation from view and initialing the mistake is also not an acceptable practice according to CMS guidelines. This method completely obscures the original documentation, which goes against the CMS requirement that all original content must be clearly identifiable.
Choice C rationale
Crossing out the error with a double line so the original documentation may be seen and dating the new entry is not specifically mentioned in the CMS guidelines. While this method does allow for the original documentation to be seen, it’s not clear whether it adheres to all CMS guidelines.
Choice D rationale
According to CMS guidelines, when making corrections to documentation, the nurse should cross out the error with a single line so the original documentation can be seen and sign and date the correction. This method ensures that all original content is clearly identifiable, which is a requirement for making corrections to documentation.

A. Respite care. B. Home health care. C. Wound care. D. Hospice care.

Correct Answer is B

Explanation

Choice A rationale
Respite care is temporary care provided to give the primary caregiver a break, which is not the primary need of a patient recovering from a hip fracture.
Choice B rationale
Home health care is the most appropriate service for a patient who has been discharged home and needs physical therapy. Home health care can provide a range of services, including physical therapy, in the patient’s home.
Choice C rationale
Wound care would be more appropriate for a patient with a wound or ulcer that requires regular dressing changes, not for a patient recovering from a hip fracture.
Choice D rationale
Hospice care is end-of-life care for patients with terminal illnesses. It is not appropriate for a patient recovering from a hip fracture.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

Correct Answer is D

Explanation

A patient has been discharged home following a hospital stay for a hip fracture sustained in a fall. The provider has ordered physical therapy to help the patient regain strength and flexibility. To which tertiary service is the patient likely to be referred?

Correct Answer is B

Explanation

A 67-year-old patient is admitted to the ICU following a myocardial infarction that has caused damage to the right side of the heart. What complication is the patient most likely to experience?

A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse’s initial action?

The nurse is observing a new nurse set up a sterile field. Which of the following actions made by the new nurse requires immediate intervention?

An ICU nurse has had many discussions with fellow nursing colleagues about allowing patient families to visit as often as the patient’s condition will allow. Which patient and family need is the nurse considering in these conversations?

A nursing student confidently communicates with a patient before performing a procedure for the first time, assuring the patient of their ability to safely carry out the procedure. This demonstrates which critical thinking attitude?

The nurse is reviewing a safety competency designed to reduce the risk of harm to patients and providers through system effectiveness and individual performance. Which group develops these safety competencies?

What events take place during systole? Select all that apply.