The nurse is using home telehealth monitoring to manage care for an 80-year-old who is homebound. The client spends most of their time in bed. Two weeks ago, the nurse detected sacral redness. Last week, it was classified as a Stage 1 pressure ulcer. On this visit, the nurse assesses the sacral area using a video camera, comparing it to the previous visit. Upon noting progression, what should the nurse do next?

Instruct the home health aide to reposition the client every 2 hours while awake.

Ask the client’s daughter to take pictures of the area and send them to the nurse.

Contact the health care provider to prescribe a hydrocolloid dressing.

Make a home visit to verify the changes in the ulcer.

Answer and Explanation

The Correct Answer is D

Choice A reason: Instructing repositioning every 2 hours is appropriate but not the first action for a progressing ulcer, seen on video. Verification via in-person assessment ensures accuracy, as video may not capture depth or infection. A home visit confirms the stage, guiding intervention, per pressure ulcer management protocols.

Choice B reason: Asking the daughter to take pictures is unreliable, as non-professional images may lack clarity or accuracy. A nurse’s in-person assessment is needed to evaluate ulcer progression, ensuring proper staging and treatment, avoiding misdiagnosis, per telehealth and wound care standards.

Choice C reason: Contacting the provider for a hydrocolloid dressing is premature without verifying the ulcer’s stage in person. Stage 1 ulcers typically require pressure relief, not advanced dressings. A home visit confirms progression, ensuring appropriate intervention, per evidence-based wound care guidelines.

Choice D reason: Making a home visit to verify ulcer changes is the priority, as video may not fully capture progression (e.g., depth, infection). In-person assessment confirms the stage, guiding accurate treatment like dressings or repositioning, preventing deterioration, per telehealth wound assessment and pressure injury protocols.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason: Setting mutual goals is important but premature without assessing the patient’s knowledge. Goals depend on understanding gaps, which are identified through assessment. Without this, goals may be irrelevant, reducing teaching effectiveness, per patient education and learning theory principles.

Choice B reason: Teaching what the patient wants to know assumes prior assessment of their needs and knowledge of their baseline. Without assessing existing knowledge, the nurse risks delivering redundant or irrelevant information, decreasing engagement and retention, per adult learning and education strategies.

Choice C reason: Assessing the patient’s current knowledge of hypertension is the first, as it establishes a baseline understanding, identifying gaps and misconceptions. This guides tailored education, ensuring relevance and effectiveness, enhancing patient engagement, and adherence to management, per patient-centered education and health literacy principles.

Choice D reason: Evaluating outcomes follows education, not precedes it. Assessment of knowledge is needed first to inform teaching. Evaluation without teaching is illogical, as there are no interventions to assess, making this step irrelevant at the start, per educational process and nursing teaching frameworks.

A. Sodium (Na+) 125 mEq/L B. Potassium (K+) 4.2 mEq/L C. Calcium (Ca+) 4.8 mg/dL D. Magnesium (Mg+) 2.0 mEq/L

Correct Answer is A

Explanation

Choice A reason: Sodium 125 mEq/L (normal 135-145 mEq/L) indicates hyponatremia, likely from excessive sweating during running, causing water retention or sodium loss. Low sodium disrupts cellular osmosis, leading to cerebral edema, explaining lethargy and pallor. This critical imbalance affects nerve conduction and muscle function, requiring urgent correction to prevent seizures or coma.

Choice B reason: Potassium 4.2 mEq/L (normal 3.5-5.0 mEq/L) is within normal range. Potassium regulates muscle and nerve function, including cardiac rhythm. Normal levels do not explain lethargy or pallor, as they ensure proper membrane potential and muscle contraction. In this scenario, potassium is not a concern compared to severe hyponatremia affecting neurological status.

Choice C reason: Calcium 4.8 mg/dL (normal 8.5-10.2 mg/dL) indicates hypocalcemia, which can cause muscle cramps or tetany. However, lethargy and pallor are more directly linked to hyponatremia’s neurological effects. Calcium affects muscle contraction and nerve signaling, but its impact is less acute than sodium’s role in osmotic balance and cerebral function here.

Choice D reason: Magnesium 2.0 mEq/L (normal 1.7-2.2 mEq/L) is normal. Magnesium supports muscle and nerve function, including ATP production. Normal levels do not contribute to lethargy or pallor, which are more likely due to sodium imbalance affecting brain hydration. Magnesium is not a priority concern in this acute presentation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is going to teach a patient about hypertension. Which action should the nurse implement first?

Correct Answer is C

Explanation

An athlete runs 5 miles a day. His wife notices that after he runs, he becomes lethargic and pale. He is still talking and responding appropriately. After being taken to the E.R., and having his lab work assessed, which lab value might the nurse be most concerned with?

Correct Answer is A

Explanation

A nurse is assigned a client who has been admitted with a high fever. Which nursing skill should the nurse use at the first contact with the client?

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

The nurse is evaluating outcomes for a patient with insomnia. Which key principle will the nurse consider during this process?

Which nursing pioneer established the Red Cross in the United States in 1882?

The patient complains of abdominal pain. Before palpating the abdomen, which action should the nurse perform?

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B?