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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale
It is a common practice for nurses to assess a patient’s respirations without explicitly stating so. This is because patients may alter their breathing pattern if they know it’s being observed.
Choice B rationale
Auscultating heart sounds using the bell of the stethoscope is a standard practice in nursing. The bell of the stethoscope is used specifically to listen to low-frequency sounds such as heart murmurs.
Choice C rationale
Assessing both carotid pulse sites at the same time is dangerous and should be avoided. This action can lead to reduced blood flow to the brain, possibly causing the patient to faint or experience a decrease in cerebral blood flow.
Choice D rationale
Cleaning the stethoscope between patient assessments is a recommended practice to prevent the spread of infections.

A. Advocacy. B. Autonomy. C. Accountability. D. Responsibility.

Correct Answer is C

Explanation

Choice A rationale
Advocacy in nursing refers to supporting, promoting, and protecting the rights, safety, and wellbeing of patients. While it is important for nurses to be able to explain their practice, this scenario does not specifically illustrate advocacy.
Choice B rationale
Autonomy in nursing refers to the right of patients to make informed decisions about their medical care. This scenario does not specifically illustrate autonomy.
Choice C rationale
Accountability in nursing refers to being answerable for one’s actions and practice. The ability to explain one’s practice to patients and employers is a key aspect of accountability.
Choice D rationale
Responsibility in nursing refers to the obligations and duties that come with the nursing role. While being able to explain one’s practice is part of a nurse’s responsibilities, it is more directly related to accountability.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

Correct Answer is C

Explanation

The nurse understands that they need to practice in a way that can be explained to the patients and employer. Which of the following terms is this an example of?

Correct Answer is C

Explanation

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The nurse is assessing the apical pulse. Where should the stethoscope be placed?

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