Question

A nurse is caring for a client who has a urinary tract infection.

Answer 1

Correct Answers:

Request a prescription for an antiemetic medication.
Clarify the prescription for amoxicillin with the provider.
Place the client on contact precautions.

Rationale :

Request a prescription for an antiemetic medication.

💎 The nurse’s notes on Day 1 and Day 2 show the client has persistent nausea (“mild nausea” and “I am just not hungry right now”), and poor oral intake, which can lead to decreased nutrition and dehydration if not addressed.

💎 Nausea is also a common adverse effect of some antibiotics and illness-related stress, so managing it helps the client tolerate food and fluids, supporting healing.

💎 The client already has a history of fever and systemic infection, so maintaining hydration and nutrition is important to support immune function and recovery.

💎 There is no antiemetic listed in the provider prescriptions, so the nurse should proactively request an antiemetic to address the ongoing symptom.

💎 Addressing nausea early helps prevent worsening weakness, electrolyte imbalance, and further decline in oral intake, which are especially risky in a client with multiple comorbidities.

Clarify the prescription for amoxicillin with the provider.

💎 The medical history clearly states the client is “Allergic to penicillin”, and amoxicillin is a penicillin-class antibiotic.

💎 Giving amoxicillin to a client with a penicillin allergy can cause serious hypersensitivity reactions, including anaphylaxis, rash, or airway compromise.

💎 Safe medication administration requires the nurse to always compare allergies with current prescriptions and act when a conflict is found.

💎 The appropriate action is to clarify or question the amoxicillin order with the provider before administration, not to give it as written.

💎 This protects the client from a potentially life-threatening reaction and demonstrates professional advocacy and patient safety.

Place the client on contact precautions.

💎 By Day 3, the nurse’s notes document increasing abdominal cramping and pain and that the client has had three loose stools since 1000.

💎 The client has been receiving antibiotics (amoxicillin) and was just prescribed metronidazole, which is often used to treat Clostridioides difficile (C. diff) infection, a common cause of antibiotic-associated diarrhea.

💎 Clients with potential or confirmed C. diff should be placed on contact precautions to prevent fecal-oral spread to other patients and staff.

💎 Contact precautions include gown and gloves on entry and using dedicated equipment, as spores can survive in the environment and are highly transmissible.

💎 Instituting contact precautions promptly once infectious diarrhea is suspected is a critical infection-control responsibility.

Recommend increasing the dose of metoprolol.

💎 The client’s blood pressure and pulse are stable (around 110–112/60–66 and pulse ~70–72/min across days), showing no need for additional BP lowering.

💎 Increasing metoprolol without a clear indication could cause hypotension or bradycardia, compromising perfusion, especially while ill.

Ensure the client wears a surgical mask when they are outside of their room.

💎 Surgical masks are used primarily for droplet or airborne infections; this client’s problem is a UTI and possible C. diff–associated diarrhea, which are managed via contact, not droplet, precautions.

💎 The priority is gown and gloves and environmental cleaning, not routine surgical mask use for this diagnosis.

Hold the dose of levothyroxine.

💎 Levothyroxine is a lifelong replacement hormone for hypothyroidism and should usually be continued during acute illness unless specifically contraindicated.

💎 Holding it without a provider order may lead to worsening hypothyroid symptoms, such as fatigue, bradycardia, and slowed metabolism, which would hinder recovery.

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Answer 2

Correct Answers

Blank 1 Correct Option: Atelectasis.
Blank 2 Correct Option: Breath sound

Rationale :

🔷 The client is post-stroke, immobile, and requires full assistance, which significantly increases the risk of alveolar collapse (atelectasis) due to shallow breathing and decreased lung expansion.

🔷 The nurse notes bilateral breath sounds decreased at the bases, which is a classic early finding for atelectasis or hypoventilation, especially in a client who is mostly in bed.

🔷 Under ABC (Airway, Breathing, Circulation) priorities, any threat to ventilation and oxygenation is addressed before gastrointestinal or skin integrity problems.

🔷 Although the client’s oxygen saturation is 93% on room air and improves to 95% on 2 L/min via nasal cannula, the decreased breath sounds show an ongoing respiratory complication risk that must be addressed early with interventions like turning, deep breathing, incentive spirometry, and coughing.

🔷 By first addressing the risk for atelectasis, the nurse helps prevent progression to pneumonia, hypoxemia, and further respiratory compromise, which are more immediately life-threatening than constipation or pressure injury.

Constipation

🔷 The client has hypoactive bowel sounds, and immobility can certainly predispose to constipation, but this is not as immediately critical as a breathing-related complication.

🔷 Constipation is important to address but falls below respiratory issues in priority according to ABC and Maslow frameworks.

Pressure injury

🔷 The client is immobile and dependent for turning, and the low prealbumin (13 mg/dL) indicates poor nutritional status, which does increase the risk for pressure injury.

🔷 However, while serious, skin breakdown is less immediately life-threatening than a developing respiratory complication like atelectasis, so it is not the first priority.

Prealbumin level

🔷 A prealbumin level of 13 mg/dL (below the normal 15–36 mg/dL) indicates malnutrition and increased risk for impaired wound healing and pressure injuries, not primarily respiratory compromise.

🔷 While important for long-term skin and recovery outcomes, it does not represent the most urgent ABC issue in this early post-stroke, immobile client.

Decreased bowel sounds

🔷 Hypoactive bowel sounds suggest reduced GI motility and risk for constipation or ileus, especially in a client with limited mobility and recent illness.

🔷 This is a valid concern but is lower priority than findings related directly to breathing and lung expansion (i.e., decreased breath sounds at the bases).

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Answer 3

Correct Answers

Blank 1 Correct Option: Aspiration
Blank 2 Correct Option: Dysphagia

Rationale :

🧠 The client has Parkinson’s disease, which commonly causes oropharyngeal and esophageal dysphagia due to impaired muscle coordination and motor control.

🧠 The nurse’s note that the client “coughs when eating” and that the voice is hoarse after swallowing are classic signs of impaired swallowing and possible aspiration of food or liquids into the airway.

🧠 The swallowing examination confirms an upper gastrointestinal motility disorder, which further supports that the client has dysphagia and difficulty safely moving the bolus from mouth to esophagus.

🧠 Dysphagia significantly increases the risk of aspiration, which can lead to aspiration pneumonia, respiratory distress, or airway obstruction, especially in neurologic conditions like Parkinson’s.

🧠 Therefore, the most accurate and priority-focused completion is that the client is at risk for aspiration due to dysphagia, and interventions like swallow precautions, modified diet, and possibly speech therapy are essential.

Circulatory overload

🧠 There is no evidence in the scenario of excess IV fluids, heart failure, kidney failure, or edema that would suggest circulatory overload.

🧠 Vital signs and assessment focus on swallowing issues, not fluid volume excess, so this is not the main risk described.

Dysrhythmias

🧠 The client’s potassium level is 3.6 mEq/L, which is within the normal range (3.5–5.0 mEq/L) and does not indicate a high risk for electrolyte-induced dysrhythmias.

🧠 There is no mention of chest pain, palpitations, or ECG changes, so dysrhythmias are not the primary concern in this context.

Temperature

🧠 The temperature is 38° C (100.4° F), which indicates a low-grade fever, possibly related to infection, but it is not the primary cause of aspiration risk.

🧠 Aspiration is more directly related to swallowing function, not mild elevation in temperature.

Potassium level

🧠 The potassium level is normal, so it does not explain any specific risk in this scenario, especially not aspiration.

🧠 Potassium abnormalities would be more associated with muscle weakness or dysrhythmias, not directly with impaired swallowing from Parkinson’s disease.

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Answer 4

Correct Answers

Blank 1 Correct Option: Aspiration
Blank 2 Correct Option: Neurological status

Rationale :

🔹 The nurse notes that on Day 2 the client is “slow to respond verbally but responds appropriately,” which signals a change in neurological status compared to Day 1 when the client was fully alert and oriented with normal strength.

🔹 The client reports “feeling food stuck in their mouth” and has a hoarse vocal quality, which are classic signs of impaired swallowing (dysphagia) and possible impaired clearance of oral secretions or food.

🔹 The presence of mild left-sided weakness suggests a possible new or evolving neurologic event (e.g., stroke/TIA), which further compromises oral-motor coordination and increases the risk of aspiration during eating or drinking.

🔹 Neurological impairment often affects the swallow reflex, cough effectiveness, and ability to safely manage oral intake, greatly increasing the risk for aspiration and aspiration pneumonia.

🔹 Therefore, based on the combination of neurologic changes, swallowing complaints, and hoarseness, the most appropriate statement is that the client is at risk for aspiration as evidenced by altered neurological status and new swallowing difficulty.

Decreased platelet count

🔹 There is no data in the exhibits indicating thrombocytopenia (no CBC, no abnormal bruising/bleeding beyond expected postop ecchymosis).

🔹 The concern here is more about neurologic and swallowing changes, not abnormal platelets.

Tachycardia

🔹 The heart rate increased from 78/min to 88/min, which is still within normal limits and not diagnostic of tachycardia (>100/min).

🔹 There is no indication that tachycardia is a primary risk or problem driving the nurse’s concern.

Sepsis

🔹 The vital signs show only a slight temperature increase to 37.4°C (99.3°F) with stable BP and RR, not meeting criteria for systemic infection or sepsis.

🔹 The new findings focus on neurologic and swallowing issues, not systemic signs of infection (no high fever, hypotension, or tachypnea).

Oxygenation

🔹 The oxygen saturation decreased slightly from 100% to 96%, which is still within normal range and does not directly indicate aspiration yet.

🔹 The risk is being identified before significant oxygenation compromise occurs; it is the neuro and swallowing changes that signal the risk.

Cardiovascular findings

🔹 The blood pressure and heart rate changes are mild and do not indicate an acute cardiac event or specific cardiovascular problem.

🔹 The major concern in this scenario is not circulation, but rather the impact of neurologic change on swallowing safety.

Enoxaparin medication

🔹 Enoxaparin use does raise bleeding risk and could relate to platelet or hemorrhage concerns, but nothing in the scenario points to active bleeding or hemodynamic compromise.

🔹 It is not the main evidence for aspiration risk; the neurologic and swallowing changes are far more relevant.

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Answer 5

Correct Answers

Blank 1 Correct Option: Hyperglycemia
Blank 2 Correct Option: Infection

Rationale :

Hyperglycemia

💎 The client has a casual glucose level of 300 mg/dL, which is well above the expected value of < 200 mg/dL, clearly indicating hyperglycemia.

💎 Clinical symptoms of thirst and frequent urination (polyuria), documented on Day 3, are classic signs of hyperglycemia and possible osmotic diuresis.

💎 Despite these symptoms, the urine specific gravity is 1.010, which is on the lower–normal side, suggesting dilute urine, supporting the idea of osmotic diuresis rather than dehydration-driven concentration.

💎 The client is receiving parenteral nutrition, which often contains high dextrose concentrations, and this is a well-known cause of elevated blood glucose, especially if insulin coverage is not adjusted.

💎 Altogether, the combination of high serum glucose, thirst, polyuria, and TPN administration strongly supports hyperglycemia as one of the key conditions reflected in the medical record.

Infection

💎 The client’s temperature increased from 37.2°C (99°F) on Day 1 to 39°C (102.2°F) on Day 3, which is a significant fever and a classic indicator of infection.

💎 The WBC count is 11,500/mm³, which is above the normal range (5,000–10,000/mm³), further supporting the presence of a systemic inflammatory or infectious process.

💎 The client is lethargic, a nonspecific but important sign that can accompany systemic infection and fever, especially in acutely ill or older clients.

💎 The presence of a PICC line and parenteral nutrition increases the risk for line-related or systemic infections, such as catheter-associated bloodstream infection.

💎 Together, the elevated temperature, increased WBC, and clinical picture point strongly toward infection as the second key condition in the chart.

Dehydration

💎 Although the client reports thirst and frequent urination, which could suggest fluid loss, the hematocrit (38%) and hemoglobin (13 g/dL) are within normal range and do not show hemoconcentration, which is typical in significant dehydration.

💎 The urine specific gravity is 1.010, which is not highly concentrated; in true dehydration, you would expect a higher specific gravity (e.g., ≥1.025) as the kidneys conserve water.

Pneumothorax

💎 The nurse notes “bilateral breath sounds clear and present throughout” on both Day 1 and Day 3, and the oxygen saturation remains 95–96% on room air, which does not support pneumothorax, where you might expect diminished or absent breath sounds and decreased SpO₂.

💎 The chest x-ray done on Day 1 confirmed the PICC line in the superior vena cava, and there is no mention of lung collapse, air in the pleural space, or respiratory distress, which would be expected with a pneumothorax.

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Answer 6

Correct Answers:

Breath sounds
Weight gain
Ankle edema

Rationale :

Breath sounds

💎 On Day 2, the nurse notes bilateral crackles at the lung bases, which is a key sign of fluid accumulation in the lungs (pulmonary congestion/pulmonary edema).

💎 This change in breath sounds from previously clear lungs indicates worsening fluid volume excess, which can rapidly progress to respiratory distress if not addressed.

💎 The respiratory rate has increased from 18/min to 24/min, and SpO₂ has dropped from 97% to 94%, supporting that the lungs are being affected by excess fluid and impaired gas exchange.

💎 Pulmonary congestion is a high-priority ABC (Airway, Breathing, Circulation) concern and requires prompt intervention, such as slowing or stopping IV fluids, elevating the head of the bed, and notifying the provider.

💎 Therefore, abnormal breath sounds with crackles are a critical finding that requires immediate follow-up to prevent acute respiratory compromise.

Weight gain

💎 The client’s weight increased from 75 kg to 77 kg in about 1 day, which is a 2 kg (~4.4 lb) gain in a very short time.

💎 In fluid balance terms, rapid weight gain reflects acute fluid retention, as 1 kg equals approximately 1 liter of fluid, suggesting the client may have retained around 2 liters of fluid.

💎 In a client receiving IV fluids (Lactated Ringer’s at 100 mL/hr), this rapid gain is a red flag for fluid volume overload.

💎 Such fluid retention is consistent with other signs in the scenario, like elevated blood pressure, crackles, and edema, indicating that the circulatory system is being overloaded.

💎 Thus, the sudden weight gain is not benign; it is a key marker of worsening fluid excess and must be followed up immediately.

Ankle edema

💎 The nurse notes 2+ pitting edema in both ankles, which is a sign of peripheral fluid accumulation and systemic volume overload.

💎 This edema develops alongside distended neck veins, another strong sign of elevated venous pressure and fluid excess, suggesting the heart and circulation are struggling to handle the volume.

💎 When peripheral edema, JVD, crackles, high BP, and tachycardia are present together, they point toward fluid volume overload and possible heart failure or fluid mismanagement.

💎 If left unaddressed, this can progress to worsening pulmonary edema, decreased oxygenation, and cardiac decompensation.

💎 Therefore, the presence of new 2+ ankle edema in this clinical context requires prompt follow-up and adjustment of the client’s fluid therapy and monitoring.

IV site

💎 The note states the IV dressing is dry and intact, with no mention of redness, swelling, pain, or infiltration, indicating the IV site is currently stable and uncomplicated.

💎 While IV sites must always be monitored, there is no urgent abnormality here compared to the more serious signs of fluid overload.

Temperature

💎 The temperature increased only slightly from 37°C (98.6°F) to 37.5°C (99.5°F), which is not considered a true fever and does not strongly suggest acute infection.

💎 In this context, the respiratory, cardiovascular, and fluid volume changes are more urgent than this mild temperature elevation.

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Answer 7

Correct Answers:

Activity level
Lactose intolerant
Vitamin D level

Rationale :

Activity level

💎 The client reports a sedentary lifestyle and also states at 6-month follow-up that they have been unable to exercise as recommended.

💎 Weight-bearing exercise (like walking) is essential for maintaining bone density, because mechanical stress stimulates bone formation.

💎 Lack of regular activity leads to reduced bone remodeling and increased bone resorption, contributing to osteoporosis risk over time.

💎 The provider previously instructed the client to “begin an exercise program”, indicating concern for bone and general health, but nonadherence keeps this risk unaddressed.

💎 Therefore, the low activity level is a clear and modifiable risk factor for osteoporosis in this client.

Lactose intolerant

💎 The client is lactose intolerant and does not take vitamin supplements consistently, which likely means reduced intake of dairy products, a major source of dietary calcium and vitamin D.

💎 Inadequate calcium intake over time impairs the ability to achieve and maintain peak bone mass and accelerates bone loss, increasing osteoporosis risk.

💎 Lactose intolerance often leads people to avoid milk and dairy, and without proper supplementation or alternative sources, chronic calcium deficiency can occur.

💎 Combined with the client’s low vitamin D level, lactose intolerance further compounds the nutritional risk to bone health.

💎 Thus, being lactose intolerant and not compensating with supplements directly contributes to increased risk for osteoporosis.

Vitamin D level

💎 The client’s 25-hydroxy vitamin D level is 24 ng/mL initially and drops further to 15 ng/mL at 6 months, both below the normal range of 25–80 ng/mL.

💎 Vitamin D is essential for calcium absorption from the gastrointestinal tract; low levels mean even if calcium is present, it is poorly absorbed, predisposing to bone demineralization.

💎 Chronic vitamin D deficiency leads to secondary hyperparathyroidism, which increases bone resorption and loss of bone density, a key mechanism in osteoporosis.

💎 The nurse’s notes show the client “frequently forgets to take their calcium and vitamin D supplements,” so this deficiency is ongoing and uncorrected.

💎 Therefore, the persistently low vitamin D level is a significant laboratory finding that places the client at risk for osteoporosis.

Alcohol use

💎 The record shows the client “does not drink alcohol”, so alcohol overuse is not a contributing risk factor in this case.

💎 While excessive alcohol intake is a known risk for osteoporosis, abstinence does not increase risk.

Smoking history

💎 The client is documented as a nonsmoker, and tobacco use is a known independent risk factor for bone loss and fractures.

💎 Since the client does not smoke, this factor does not contribute to their osteoporosis risk profile.

Phosphorus level

💎 The phosphorus levels (3.4 and 3.2 mg/dL) remain within normal range (3–4.5 mg/dL), so there is no clear phosphorus abnormality to explain increased osteoporosis risk.

💎 While severe chronic phosphorus disturbances can affect bone, these values are not significantly abnormal and are not the key issue here compared to inactivity, low vitamin D, and probable low calcium intake.

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Answer 8

Correct Answers:

Informed consent
Allergies
Dietary intake

Rationale :

Informed consent

🔹 The chart states that “informed consent obtained” and placed in the record, but it also documents that the client is expressing concern about potential complications from surgery.

🔹 When a client voices fear or concern about complications, this may indicate that they do not fully understand the procedure, risks, or alternatives, which calls into question whether their consent is truly informed.

🔹 The nurse has a duty to assess the client’s understanding, clarify what is within nursing scope, and notify the surgeon if the client has unanswered questions or lingering doubts.

🔹 Surgery should ideally proceed only when the client’s consent is both voluntary and informed, meaning their concerns have been properly addressed by the provider performing the procedure.

🔹 Therefore, even though a consent form is signed, the client’s expressed concerns require follow-up to ensure valid informed consent prior to surgery.

Allergies

🔹 The client is documented as allergic to shellfish, latex, and penicillin, all of which have serious implications for perioperative care.

🔹 A latex allergy is especially critical in the operating room, where many gloves, catheters, and equipment components may contain latex and must be replaced with latex-free alternatives.

🔹 A penicillin allergy affects the choice of preoperative antibiotic prophylaxis, and the surgeon/anesthesia team must be clearly aware so they can choose a safe alternative.

🔹 The shellfish allergy is also important to communicate, as some facilities associate it (correctly or not) with caution around iodine-based contrast or antiseptics, and this may influence skin prep decisions or require verification of products used.

🔹 Because allergic reactions in the OR can be rapid and life-threatening, the client’s allergy profile needs explicit follow-up and communication to the entire surgical team before proceeding.

Dietary intake

🔹 The client ate toast at 0600, and now it’s later in the morning (around 1050–1200), which means they have not been NPO for very long for solid food.

🔹 For general anesthesia, standard guidelines recommend NPO for solids for about 6–8 hours to reduce the risk of aspiration during induction.

🔹 Because this is urgent/emergent surgery (acute appendicitis), the operation may still need to proceed, but the anesthesia team must be informed of recent oral intake to adjust airway and aspiration risk management.

🔹 This finding requires follow-up so that NPO status is clarified, documented, and communicated to the anesthesiologist before surgery.

🔹 Thus, the client’s recent dietary intake is a critical preoperative factor that requires immediate follow-up prior to surgery.

Blood pressure

🔹 The blood pressure is 124/80 mm Hg, which is within a normal/acceptable range and not indicative of acute hemodynamic instability.

🔹 There is no evidence of severe hypertension or hypotension, so BP does not require special follow-up before surgery in this scenario.

Oxygen saturation

🔹 The oxygen saturation is 96% on room air, which is within the expected normal range (95–100%) and indicates adequate oxygenation.

🔹 There are no respiratory signs (e.g., dyspnea, low SpO₂) suggesting a need for urgent respiratory optimization before surgery.

Pain level

🔹 The client’s pain has increased from 6/10 to 8/10, which is expected in acute appendicitis and is part of the reason they are proceeding to urgent surgery.

🔹 While pain management is important, it does not take priority over ensuring allergies, NPO status, and informed consent are appropriately addressed prior to anesthesia and surgery.

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Answer 9

Correct Highlights :

Client will not look at the stoma.
Client states they are not interested in learning about stoma care.
Skin surrounding the stoma is reddened and appears irritated.
Urine output: 650 ml over the last 24 hr.

Rationale :

Client will not look at the stoma

💎 Refusing to look at the stoma indicates impaired body image and difficulty accepting the new change in body function and appearance.

💎 Early emotional reactions such as avoidance or denial are common after ostomy surgery, but they require therapeutic communication and support from the nurse.

💎 If the client will not look at the stoma, they are unlikely to participate in self-care, which is critical for long-term independence and safety at home.

💎 The nurse should gently encourage the client, involve them gradually (e.g., looking in a mirror, touching the pouch), and consider referral to an ostomy support group.

💎 Addressing this now helps prevent long-term psychological distress and dependence on others for basic care.

Client states they are not interested in learning about stoma care

💎 Verbalizing lack of interest in learning ostomy care reflects low readiness for learning and possible denial, fear, or depression.

💎 Because an ileostomy requires daily, lifelong self-management, the client must eventually become competent in pouch changes, skin care, and monitoring output.

💎 The nurse should explore the client’s feelings and concerns, provide emotional support, and use motivational and stepwise teaching strategies to build engagement.

💎 Failure to address this issue increases risk of skin breakdown, leakage, infection, and hospital readmission once the client is discharged.

💎 Early intervention supports both physical safety and psychosocial adaptation to living with an ostomy.

Skin surrounding the stoma is reddened and appears irritated

💎 Red, irritated peristomal skin indicates breakdown or early dermatitis, usually caused by leakage of enzyme-rich ileostomy effluent onto the skin.

💎 Ileostomy output is liquid and highly caustic, so untreated irritation can quickly progress to painful excoriation, infection, and difficulty maintaining a pouch seal.

💎 The nurse should assess the pouch fit, ensure the opening is cut to the correct size, and use skin barrier products to protect the peristomal area.

💎 The record shows a referral to an ostomy nurse, which is appropriate, but nursing care is still needed immediately to manage irritation until the specialist sees the client.

💎 Protecting the skin is essential for wear-time, comfort, and prevention of complications, so this finding clearly requires intervention.

Urine output: 650 mL over the last 24 hr

💎 On Day 2, the urine output is 650 mL/24 hr, which is low for an adult (normal is ≈ >30 mL/hr or >720 mL/24 hr), especially compared to the previous day’s 1,200 mL.

💎 Ileostomy clients are at high risk for fluid volume deficit because they lose large amounts of fluid and electrolytes through liquid stool.

💎 The decrease in intake (1,600 mL) and drop in urine output suggest the client may be getting dehydrated, even if specific gravity isn’t provided here.

💎 Early signs of dehydration require prompt nursing action: encouraging oral fluids, monitoring vital signs and output closely, and notifying the provider if output remains low.

💎 Addressing reduced urine output helps prevent acute kidney injury, electrolyte imbalance, and hemodynamic instability in a high-risk ileostomy patient.

Ileostomy stoma is pink

💎 A pink, moist stoma is an expected and healthy finding, indicating adequate blood flow to the stoma.

💎 Intervention would be needed if the stoma were pale, dusky, or black, which would suggest ischemia, but that is not present here.

Stoma draining moderate brown liquid stool

💎 An ileostomy normally produces liquid to semi-liquid stool, often brown in color once intake resumes.

💎 This output is expected and indicates functional intestinal drainage, not a complication.

Intake: 2,200 mL over the last 24 hr

💎 An intake of 2,200 mL/24 hr on Day 1 is adequate fluid intake, especially appropriate for an ileostomy client who needs good hydration.

💎 This value itself is not problematic; the concern emerges later with reduced intake and low urine output, not this initial intake figure.

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Answer 10

Correct Answers:

Left lower extremity tenderness

Rationale :

🟣 Prolonged bed rest greatly increases the risk for venous thromboembolism (VTE), especially deep vein thrombosis (DVT) in the lower extremities.

🟣 Tenderness in one lower extremity, particularly if accompanied by warmth, redness, or swelling, is a classic sign of a possible DVT.

🟣 A DVT can progress to a pulmonary embolism, which is life-threatening and therefore takes priority over other more chronic issues like weakness or appetite changes.

🟣 Using priority frameworks like ABC and safety, a potential DVT is a critical circulatory problem that must be assessed and managed immediately.

🟣 The nurse should notify the provider, avoid massaging the area, and anticipate diagnostic testing (e.g., Doppler ultrasound) and anticoagulation therapy.

Increased heart rate during physical activity

🟣 A mild increase in heart rate with activity can be an expected finding due to deconditioning after prolonged bed rest.

🟣 This is not as emergent as a localized sign suggestive of DVT.

Musculoskeletal weakness

🟣 Weakness is a common, expected outcome of immobility and can be addressed with gradual activity and physical therapy.

🟣 It is important but not as immediately life-threatening as a potential DVT.

Loss of appetite

🟣 Decreased appetite may occur with immobility, mood changes, or hospital environment, but it is a less urgent concern.

🟣 It does not pose the same acute risk as a possible DVT that could embolize.

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Rn mental health 2023 1242025

No.

1 :
A nurse is caring for a client who has a urinary tract infection.

Answer Options

2 :
A nurse is caring for a client.

Correct Answers

3 :
A nurse is caring for a client.

Correct Answers

4 :
A nurse at a rehabilitation facility is caring for a client who was admitted the previous day.

Correct Answers

5 :
A nurse is reviewing the medical record of a client who has a paralytic ileus.

Correct Answers

6 :
A nurse is caring for a client.

Answer Options

7 :
A nurse in a provider's office is caring for a client.

Answer Options

8 :
A nurse is caring for a client who is scheduled for an appendectomy.

Answer Options

9 :
A nurse is caring for a client who has an ileostomy.

Correct Highlights :

10 :
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?

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Rn mental health 2023 1242025

No.

1 : A nurse is caring for a client who has a urinary tract infection.

Answer Options

2 : A nurse is caring for a client.

Correct Answers

3 : A nurse is caring for a client.

Correct Answers

4 : A nurse at a rehabilitation facility is caring for a client who was admitted the previous day.

Correct Answers

5 : A nurse is reviewing the medical record of a client who has a paralytic ileus.

Correct Answers

6 : A nurse is caring for a client.

Answer Options

7 : A nurse in a provider's office is caring for a client.

Answer Options

8 : A nurse is caring for a client who is scheduled for an appendectomy.

Answer Options

9 : A nurse is caring for a client who has an ileostomy.

Correct Highlights :

10 : A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?

1 :
A nurse is caring for a client who has a urinary tract infection.

2 :
A nurse is caring for a client.

3 :
A nurse is caring for a client.

4 :
A nurse at a rehabilitation facility is caring for a client who was admitted the previous day.

5 :
A nurse is reviewing the medical record of a client who has a paralytic ileus.

6 :
A nurse is caring for a client.

7 :
A nurse in a provider's office is caring for a client.

8 :
A nurse is caring for a client who is scheduled for an appendectomy.

9 :
A nurse is caring for a client who has an ileostomy.

10 :
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?