When a client with diarrhea becomes diaphoretic, the practical nurse (PN) measures the client's vital signs and finds that the client is febrile with a rapid pulse and respiratory rate and a slightly decreased blood pressure. Which additional assessment finding is this client likely to exhibit?

Bounding pulse.

Polyuria

Peripheral edema.

Poor skin turgor.

Answer and Explanation

The Correct Answer is D

Rationale:
A. This option is incorrect because a bounding pulse is typically seen in conditions of fluid overload, high cardiac output, or hyperdynamic states such as fever or anxiety. In this case, the client is experiencing fluid loss from diarrhea and diaphoresis, which would more likely result in a weak, thready pulse due to decreased circulating blood volume, not a bounding one.

B. This option is incorrect because polyuria (excessive urination) is unlikely in a client with significant fluid loss. Diarrhea and diaphoresis cause volume depletion, and the body typically responds by conserving fluid, resulting in oliguria (decreased urine output).

C. This option is incorrect because peripheral edema occurs when there is fluid retention, such as in heart failure, renal failure, or hypoalbuminemia. The client in this scenario is losing fluids, making edema highly unlikely.

D. This option is correct because poor skin turgor is a hallmark sign of dehydration, which develops when fluid loss exceeds intake. In this client, ongoing diarrhea combined with diaphoresis and fever leads to extracellular fluid depletion, which reduces skin elasticity. Clinically, poor skin turgor is assessed by gently pinching the skin over the forearm or sternum and observing if it returns slowly to its normal position.

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Correct Answer is C

Explanation

Rationale:
A. This option is incorrect because active listening is an important communication technique that helps build trust and clarify understanding, but by itself it does not directly enhance an adult learner’s ability to acquire and perform a new hands-on skill such as surgical wound care.

B. This option is incorrect because advising about community resources focuses on support services rather than the learning process. While helpful for long-term management, it does not directly assist the client in mastering the skill of wound dressing.

C. This option is correct because adult learning theory (andragogy) emphasizes that adults bring a wealth of prior knowledge, experiences, and problem-solving skills to the learning environment. By assessing the client’s life experiences, the PN can relate new wound-care skills to tasks the client has already performed, tailor instruction to the client’s background, and make the learning relevant and practical. This approach improves understanding, confidence, and skill retention.

D. This option is incorrect because exploring several treatment options focuses on shared decision-making rather than teaching the step-by-step process of a specific skill. When learning a new task, adults benefit most from instruction that builds on their existing experiences rather than evaluating multiple options.

A. Propose to notify the family of the request. B. Explore the client's thoughts about dying. C. Suggest that the hospital chaplain is available. D. Offer to contact the priest for the client.

Correct Answer is D

Explanation

Rationale:
A. This option is incorrect because notifying the family may be appropriate later if the client wishes, but the immediate priority is to honor the client’s spiritual request. Delaying the request could cause distress.

B. This option is incorrect because exploring the client’s thoughts about dying, while supportive, does not address the expressed need for religious rites at the end of life. Spiritual requests take priority in hospice care when the client is actively requesting them.

C. This option is incorrect because suggesting the hospital chaplain may not meet the client’s specific religious preference. The client requested a priest for the “Last Rites,” which is a distinct sacramental ritual that requires a priest.

D. This option is correct because the PN should immediately act to fulfill the client’s request by contacting the priest. This ensures the client’s spiritual needs are met, provides comfort, and respects the client’s autonomy and end-of-life wishes. Prompt action aligns with hospice care principles, which prioritize dignity, comfort, and spiritual support.

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When a client with diarrhea becomes diaphoretic, the practical nurse (PN) measures the client's vital signs and finds that the client is febrile with a rapid pulse and respiratory rate and a slightly decreased blood pressure. Which additional assessment finding is this client likely to exhibit?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is reinforcing teaching about covering a surgical wound with an adult leaner. Which adult learning approach will best support the client in learning a new skill?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a hospice client who requests a priest for the "Last Rites." Which should be the next response by the PN?

Correct Answer is D

Explanation

The practical nurse (PN) tells the unlicensed assistive personnel (UAP) that an immobile client is at risk for the development of contractures. The UAP replies that compression stockings have been applied to the client's lower extremities. Which action should the PN take next?

The practical nurse (PN) is reinforcing teaching with a client on the proposed plan of care. Which step(s) should the nurse implement to facilitate the client's adherence to a plan of care? Select all that apply.

The practical nurse (PN) enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. Which action should the PN implement first?

Patient Data Which should the practical nurse (PN) do immediately after intestinal tissue is noted protruding from the wound? Select all that apply.

An ambulatory client with an indwelling urinary catheter is requesting to take a shower for the first time. Which is the best intervention for the practical nurse (PN) to implement?

After applying an alcohol-based hand rub to the palms of the hand and rubbing the palms together, which action should the practical nurse take next?

The practical nurse (PN) is using guided imagery with a client who is experiencing chronic pain. The PN should direct the client's attention to which focus?