◉ Client confusion action. Answer: The PN should remind the client
what day of the week it is when she forgets or becomes confused.
◉ Rationale for client confusion. Answer: Relocation often results in
confusion among elderly clients during times of adjustment to new
surroundings.
◉ Stomatitis assessment focus. Answer: The PN should gather
information related to the client's ability to swallow.
◉ Rationale for swallowing assessment. Answer: Stomatitis or
inflammation of the oral mucosa can cause pain and result in
difficulty in swallowing.
◉ Priority action post-endoscopic procedure. Answer: Assess the
gag reflex.
◉ Ondansetron effectiveness evaluation. Answer: Monitor the client
for nausea and vomiting following the treatment.
,◉ Rationale for ondansetron use. Answer: Ondansetron is an
antiemetic administered prior to chemotherapy to prevent post-
treatment nausea and vomiting.
◉ Skin assessment in dark-skinned clients. Answer: Observe the
sclera and mucous membranes.
◉ Complication after colon resection. Answer: Sudden spillage of
serosanguinous drainage from the client's wound followed by
appearance of bowel on the skin indicates a complication.
◉ Evisceration. Answer: The complete separation of a wound with
protrusion of the viscera, which usually occurs 7-10 days
postoperatively.
◉ Dehiscence. Answer: Not explicitly defined in the notes.
◉ Hemorrhage. Answer: Not explicitly defined in the notes.
◉ Infection. Answer: Not explicitly defined in the notes.
◉ Low serum sodium level. Answer: A serum sodium level of 125
mEq/L, which may be the result of water intoxication.
,◉ Normal serum sodium level. Answer: The normal range for serum
sodium is 135-145 mEq/L.
◉ Fall prevention protocol. Answer: A new protocol being
implemented on the medical unit to ensure patient safety.
◉ Scope of practice for a practical nurse (PN). Answer: Includes
discharge teaching about newly prescribed medications, presenting
support options for cancer patients, teaching glucometer use, and
demonstrating deep breathing and coughing techniques.
◉ Impaired mobility nursing diagnosis. Answer: A diagnosis related
to fear of falling in an older postoperative client.
◉ Desired outcome for impaired mobility. Answer: The client will
ambulate with assistance q4 hours.
◉ Risk factors for laryngeal cancer. Answer: Higher prevalence in
older males who smoke and drink excessively.
◉ Informed consent. Answer: A process where a client agrees to
undergo a surgical procedure after being informed of the risks.
, ◉ Priority action for client concerns. Answer: Notify the charge
nurse of the client's concerns about surgery.
◉ Dizziness assessment. Answer: Standing blood pressure
◉ UAP feedback response. Answer: Approach the UAP to discuss the
behavior and obtain the information needed about the client
◉ Professional behavior in nursing. Answer: Maintaining channels of
communication and ensuring open and honest communication
focused directly on the related issues
◉ Pain management intervention for fractured metatarsals. Answer:
Implement ongoing assessments for signs of shallow or slow
breathing
◉ Distraction technique during painful procedure. Answer:
Encourage the client to reminisce about a favorite past family event
◉ Costochondritis care intervention. Answer: Implement ongoing
assessments for signs of shallow or slow breathing