PN Comprehensive Predictor 2020

Extract:

Vital Signs
05:00
Temperature 36.6 C (97.9 F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 160/98 mm Hg
Oxygen saturation 96% on oxygen 2 L/min via nasal cannula
14:00
Temperature 36.8 C (98.3 F)
Heart rate 90/min
Respiratory rate 18/min
Blood pressure 138/88 mm Hg
Oxygen saturation 97% on oxygen 2 L/min via nasal cannula

Question 1 of 5

A nurse is assisting with the care of a client in a medical-surgical unit. Vital Signs 05:00 Temperature 36.6 C (97.9 F) Heart rate 100/min Respiratory rate 22/min Blood pressure 160/98 mm Hg Oxygen saturation 96% on oxygen 2 L/min via nasal cannula 14:00 Temperature 36.8 C (98.3 F) Heart rate 90/min Respiratory rate 18/min Blood pressure 138/88 mm Hg Oxygen saturation 97% on oxygen 2 L/min via nasal cannula Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.

A. Encourage the client to drink 3,000 mL of fluid daily. B. Change the indwelling urinary catheter tubing every 3 days. C. Place the drainage bag on the bed when transporting the client. D. Empty the drainage bag when it is half-full. E. Review the need for the indwelling urinary catheter daily. F. Use soap and water to provide perineal care.

Correct Answer: A,D,E,F

Rationale: High fluid intake flushes bacteria, frequent emptying prevents growth, daily review minimizes catheter use, and soap/water cleaning reduces infection risk. Tubing changes and bag placement increase risk.

Extract:

Nurses Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Question 2 of 5

Nurses Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, 'I don't know. Ask them.' Client's child states, 'He gets confused sometimes. I can answer your questions.' The nurse is identifying tertiary prevention strategies to implement for this client. Select the three actions the nurse should take.

A. Insist that the client explain the reason for their bruises. B. Inform the client that their child is being abusive toward them. C. Report suspected maltreatment to the appropriate agency. D. Confront the client's child about the client's injuries. E. Ask the client how the fracture occurred. F. Conduct the interview with the client privately.

Correct Answer: C,E,F

Rationale: Reporting suspected abuse, asking about the fracture, and interviewing privately are tertiary prevention steps to address and mitigate harm. Insisting, informing, or confronting may escalate without evidence.

Extract:

Question 3 of 5

A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

A. I will limit my time in the tanning bed to 15 minutes. B. I will dry my skin by patting it with a towel. C. I will use an astringent on my face. D. I will cleanse my skin using an antibacterial soap.

Correct Answer: B

Rationale: Patting skin dry is gentle and appropriate for SLE, which can cause skin sensitivity. Tanning beds worsen symptoms, and astringents or antibacterial soaps may irritate.

Question 4 of 5

A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?

A. Encourage the client to bathe frequently. B. Apply powder to the client's skin. C. Add moisturizing oil to the client's bath water. D. Place a humidifier in the client's room.

Correct Answer: D

Rationale: A humidifier adds moisture to the air, relieving dry, itchy skin common in older adults. Frequent bathing or powder dries skin further, and bath oil is less effective long-term.

Question 5 of 5

A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

A. Droplet precautions B. Airborne precautions C. Protective environment D. Contact precautions

Correct Answer: D

Rationale: Herpes simplex spreads via direct contact, requiring contact precautions (gloves, gown). Droplet, airborne, and protective environments are for other transmission modes.

PN Comprehensive Predictor 2020 | Nurselytic

Nurselytic

ATI LPN

ATI LPN