When caring for a client with severe diarrhea, which focused assessment is most important for the practical nurse (PN) to complete before reporting to the charge nurse?

Check for external rectal hemorrhoids.

Note inflammation in the perineal area.

Observe for signs of fluid volume deficit.

Determine any changes in sleep patterns.

Answer and Explanation

The Correct Answer is C

A. Check for external rectal hemorrhoids: Hemorrhoids may cause discomfort during diarrhea, but they are not the most urgent concern. The primary issue with severe diarrhea is the risk of dehydration and electrolyte imbalance, which can become life-threatening.
B. Note inflammation in the perineal area: While important for skin care and comfort, perineal inflammation does not pose the immediate systemic risk that fluid volume deficit does. Skin assessment can be addressed after ensuring the client's vital signs and hydration status are stable.
C. Observe for signs of fluid volume deficit: Severe diarrhea leads to significant fluid and electrolyte losses. Signs such as hypotension, tachycardia, dry mucous membranes, and decreased urine output indicate fluid volume deficit, which requires urgent intervention to prevent shock and organ dysfunction.
D. Determine any changes in sleep patterns: Sleep disturbances can occur with illness but are not as immediately critical to assess as fluid and electrolyte status. Identifying fluid volume deficit must be prioritized to prevent rapid clinical deterioration.

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Correct Answer is C

Explanation

A. Provide a PRN hypnotic medication: Administering a hypnotic should not be the first response without first assessing the underlying cause of the sleep difficulty. Non-pharmacological approaches are safer, especially for older adults who are more sensitive to sedative side effects.
B. Reassure the client that it is still early: Simply reassuring the client does not address the immediate concern of why the client cannot sleep. Dismissing the complaint without assessment may lead to prolonged distress and unresolved sleep disturbances.
C. Evaluate the room environment: Assessing the room for factors like noise, lighting, temperature, and comfort is a priority because environmental factors often contribute significantly to insomnia. Addressing modifiable conditions can promote natural sleep without immediately resorting to medications.
D. Close the door to the client's room: While closing the door might reduce noise, it is a single action that may not fully address all potential environmental issues affecting sleep. A complete evaluation of the environment is necessary first to identify and correct all possible disruptions.

A. Standards of practice for practical nursing. B. The licensing state's PN scope of practice. C. Geriatric standards of care guidelines. D. The employing agency's procedure manuals.

Correct Answer is B

Explanation

A. Standards of practice for practical nursing: While important for general nursing care, national or professional standards do not replace the specific legal requirements outlined by the state’s licensing authority, which directly govern what a PN can and cannot do.
B. The licensing state's PN scope of practice: Each state defines the legal scope of practice for practical nurses, including what tasks they are authorized to perform. Reviewing the specific state's scope of practice ensures the PN practices legally and professionally in the new employment setting.
C. Geriatric standards of care guidelines: Geriatric care guidelines help provide quality care for older adults but are not the first priority when ensuring lawful nursing practice across state lines. Legal requirements must be understood first.
D. The employing agency's procedure manuals: While agency policies are important for specific job performance, they must be aligned with the state's legal scope of practice. Knowing the legal boundaries first is crucial before following any workplace procedures.

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When caring for a client with severe diarrhea, which focused assessment is most important for the practical nurse (PN) to complete before reporting to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) the inability to fall asleep. Which is the priority nursing action?

Correct Answer is C

Explanation

After accepting employment in a state different from where a practical nurse (PN) is currently employed, it is most important for the PN to review which reference?

Correct Answer is B

Explanation

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