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A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.
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A health care agency has different receptacles for the various categories of institutional waste. Into which container should the nurse dispose of a suction canister used to collect bloody drainage from the client's NG tube?
- A. Injurious waste receptacle
- B. Hazardous waste receptacle
- C. Infectious waste receptacle
- D. Wastebasket in the client's bathroom
Correct Answer: C
Rationale: Blood and body fluids are classified as infectious waste, requiring disposal in the infectious waste receptacle.
Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
- A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
- B. If the client is dizzy on standing, ask him to take some deep breaths.
- C. Assist the client to the bathroom at least twice on this shift.
- D. After you assist him to the chair, let me know how he feels.
Correct Answer: A
Rationale: Give clear information to the UAP about what is expected for client safety. This instruction ensures the client is assessed for orthostatic hypotension before ambulating, reducing the risk of falls.
The client had a THR. The nurse is discussing home modifications with the client's son. Which modifications should the nurse recommend? Select all that apply.
- A. Pad bed side rails.
- B. Install safety bars around the toilet and shower.
- C. Install an elevated toilet seat in the bathroom.
- D. Plan for the client's bed to be in a main floor room.
- E. Use a nonskid bathmat in the bathtub for the client's daily bath.
- F. Remove scatter rugs and secure electrical cords against baseboards.
Correct Answer: B,C,D,F
Rationale: B: Safety bars aid mobility. C: Elevated toilet seat prevents excessive hip flexion. D: Main floor bedroom avoids stairs. F: Removing rugs and cords prevents tripping. A is unnecessary, and E is incorrect as tub baths are avoided post-THR.
A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:
- A. The baby will eventually take to the breast.
- B. I can fix up a bottle if you want to try that.
- C. A small amount of weight loss in the first few days is normal.
- D. I can get the charge nurse to come and talk to you about breast-feeding.
Correct Answer: C
Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.