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A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
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A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
- A. Akathisia
- B. Tardive dyskinesia
- C. Dystonia
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Tardive dyskinesia is a common adverse effect of long-term antipsychotic medication use, such as chlorpromazine. It is characterized by involuntary movements of the tongue and face. This condition is often irreversible and can be distressing for the client. Akathisia (choice A) is a different extrapyramidal side effect characterized by restlessness and the urge to move constantly. Dystonia (choice C) is another extrapyramidal side effect that presents as sustained muscle contractions causing abnormal postures. In this case, the symptoms described in the question are more indicative of tardive dyskinesia due to the specific type of involuntary movements observed in the client.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
- A. The medication will reduce inflammation.
- B. The medication will decrease coughing episodes.
- C. The medication will prevent wheezing.
- D. The medication will open the airway.
- E. The medication will stimulate the flow of mucus.
Correct Answer: C,D
Rationale: Correct Answer: C,D
Rationale:
C: The medication will prevent wheezing. Albuterol is a bronchodilator that works by relaxing the muscles in the airways, preventing and relieving wheezing.
D: The medication will open the airway. Albuterol acts by opening the airways, making it easier for the client to breathe.
Summary:
A: The medication will reduce inflammation. Albuterol does not directly reduce inflammation; it primarily works as a bronchodilator.
B: The medication will decrease coughing episodes. While albuterol may indirectly reduce coughing by improving breathing, its primary action is not to decrease coughing.
E: The medication will stimulate the flow of mucus. Albuterol does not stimulate mucus flow; it primarily works to open the airways and relieve bronchospasm.
A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
- A. Verify the provider’s prescription to discontinue the tube.
- B. Disconnect the tube from the wall suction.
- C. Perform hand hygiene.
- D. Provide mouth care to the client.
Correct Answer: A
Rationale: The correct answer is A: Verify the provider’s prescription to discontinue the tube. This is the first step because removing an NG tube without a prescription could lead to serious complications. The nurse must ensure that it is safe and appropriate to remove the tube as per the provider's orders. Disconnecting the tube from the wall suction (B) should only be done after verifying the prescription. Performing hand hygiene (C) and providing mouth care to the client (D) are important steps in the process but should come after confirming the prescription.
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?
- A. Leave the pad in place for at least 40 minutes
- B. Set the pad’s temperature to 42.2°C (108°F)
- C. Use safety pins to keep the pad in place
- D. Stop the treatment if the client’s skin becomes red
Correct Answer: D
Rationale: The correct answer is D: Stop the treatment if the client’s skin becomes red. This is important because redness indicates potential skin damage or burns due to excessive heat exposure. It is crucial to monitor the client's skin during heat application to prevent harm. Choice A is incorrect because leaving the pad in place for a specific duration can lead to skin damage if the temperature is too high. Choice B is incorrect as setting the pad's temperature too high can cause burns. Choice C is incorrect as safety pins can cause injury or discomfort to the client. Therefore, the correct action is to closely monitor the client's skin for any signs of redness and stop the treatment immediately if redness occurs to prevent further harm.
A nurse is preparing to administer ampicillin and gentamicin sulfate via IV infusion. Which of the following resources should the nurse consult first regarding medication compatibility?
- A. Health care provider
- B. Hospital pharmacist
- C. Nurse manager
- D. Medication sales representative
Correct Answer: B
Rationale: The correct answer is B: Hospital pharmacist. The nurse should consult the pharmacist first for medication compatibility as they are experts in drug interactions and compatibility. Pharmacists can provide specific guidance on whether ampicillin and gentamicin sulfate can be safely administered together via IV infusion. Consulting the health care provider (choice A) may also be necessary for prescribing information, but pharmacists have specialized knowledge on drug interactions. The nurse manager (choice C) may not have the expertise in medication compatibility. Consulting a medication sales representative (choice D) is not appropriate as their role is to promote and sell medications rather than provide clinical guidance on compatibility.