Which intervention should the nurse implement for a client?

Maintain in high Fowler’s position.

Report any change in urine color.

Keep mucous membranes moist.

Record the client’s daily weight.

Answer and Explanation

The Correct Answer is C

Choice A reason: High Fowler’s position aids breathing in respiratory distress but is not universally indicated without context. It may strain the client’s back or increase fatigue if sustained. Keeping mucous membranes moist is a broader intervention, preventing complications like oral infections or discomfort, especially in dehydrated or oxygen-dependent clients, making it more appropriate.

Choice B reason: Reporting changes in urine color monitors renal or hydration status but is less immediate than maintaining mucous membranes. Dry membranes risk infection or discomfort, particularly in clients on oxygen or with reduced oral intake. Urine monitoring is secondary, as it reflects longer-term changes rather than addressing an urgent physiological need.

Choice C reason: Keeping mucous membranes moist prevents drying, which can lead to infections, discomfort, or impaired swallowing. This is critical for clients on oxygen, with reduced intake, or in dry environments. Moist membranes support airway protection and comfort, aligning with nursing priorities to maintain basic physiological functions and prevent complications.

Choice D reason: Recording daily weight tracks fluid status or nutritional changes but is less urgent than moist mucous membranes. Dry membranes pose immediate risks like infection or airway irritation, especially in vulnerable clients. Weight monitoring is a longitudinal assessment, secondary to addressing acute comfort and infection prevention needs.

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Correct Answer is B

Explanation

Choice A reason: Checking for staff with fitted N95 masks before reassigning tasks is time-consuming and unnecessary. Streptococcal pharyngitis spreads via large respiratory droplets, requiring only droplet precautions with a standard surgical mask, gloves, and eye protection. N95 respirators are reserved for airborne pathogens or aerosol-generating procedures, which are not indicated here. This action delays care and misallocates resources, as the UAP can safely respond with standard precautions.

Choice B reason: A standard face mask suffices for droplet precautions, as streptococcal pharyngitis is transmitted through large respiratory droplets, not fine aerosols. CDC guidelines endorse surgical masks, gloves, and eye protection for routine care of such patients. N95 masks are unnecessary unless aerosol-generating procedures occur. This option ensures immediate, safe care delivery while adhering to evidence-based infection control protocols.

Choice C reason: Sending the UAP for immediate N95 fitting is inefficient and unwarranted. The fitting process requires trained personnel and time, delaying patient care. Droplet precautions for streptococcal pharyngitis do not require N95 masks, as the pathogen is not airborne. This action overcomplicates the response, misaligns with CDC guidelines, and diverts focus from the patient’s immediate needs.

Choice D reason: Advising the UAP to use a standard mask for vital signs and later get fitted for an N95 for personal care is unnecessarily complex. Droplet precautions with a standard mask are sufficient for all routine interactions with this client. Requiring an N95 for personal care escalates precautions without scientific basis, delays care, and misuses resources.

A. Multiple hard pellets. B. Formed but soft. C. Solid with red streaks. D. Tarry appearance. E. Brown liquid.

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Hard pellets indicate constipation, potentially due to dehydration, low fiber, or medication side effects. This warrants follow-up to prevent impaction or discomfort. Constipation can lead to straining, hemorrhoids, or bowel obstruction, requiring interventions like hydration, dietary changes, or laxatives to restore normal bowel function and client comfort.

Choice B reason: Formed but soft stools are normal, reflecting healthy bowel function with adequate hydration and fiber. This description does not require follow-up, as it indicates no immediate pathology. Normal stools vary in consistency, but soft, formed stools align with optimal gastrointestinal health, requiring no further nursing intervention at this time.

Choice C reason: Solid stools with red streaks suggest fresh blood, possibly from hemorrhoids, fissures, or lower gastrointestinal bleeding. This requires urgent follow-up to identify the source and assess bleeding severity. Blood in stools can indicate serious conditions like colorectal pathology, necessitating diagnostic evaluation and intervention to prevent complications.

Choice D reason: Tarry stools indicate melena, suggesting upper gastrointestinal bleeding, possibly from ulcers or gastritis. This is a critical finding requiring immediate follow-up to assess hemoglobin, vital signs, and bleeding source. Melena can lead to anemia or shock if untreated, making prompt nursing assessment and intervention essential for client safety.

Choice E reason: Brown liquid stools suggest diarrhea, potentially from infection, medication, or dietary issues. This warrants follow-up to assess dehydration, electrolyte imbalance, or infectious causes like C. difficile. Diarrhea risks skin breakdown and fluid loss, requiring nursing interventions like fluid replacement and stool testing to address underlying causes.

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Which intervention should the nurse implement for a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) is asked to answer the call light for a client with streptococcal pharyngitis for whom droplet precautions have been implemented. The UAP refuses, informing the nurse of not being fitted for an N95 respirator mask. Which action should the nurse take?

Correct Answer is B

Explanation

The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which description(s) warrant additional follow-up by the nurse? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

After an IV antibiotic is started, the nurse discovers that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

A client arrives to a clinic appointment reporting sexual dysfunction for the past three months. Which condition should the nurse expect to see in the client’s medical record?

The nurse is caring for a client who wears bilateral hearing aids. Which action should the nurse take when communicating with the client?

The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client is lethargic and very weak. Before providing mouth care, the nurse plans to assess the client’s gag reflex. Which action should the nurse include?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?