Nokea
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- A. Obtain a raised toilet seat for the bathroom.
- B. Secure loose wires under carpeting.
- C. Use extension cords to prevent overloading circuits.
- D. Cover slippery stairs with an area rug.
Correct Answer: A
Rationale: The correct answer is A: Obtain a raised toilet seat for the bathroom. This is important for older adults to prevent falls and make it easier for them to use the toilet safely. Raised toilet seats reduce the risk of strain or injury while sitting down or getting up.
Incorrect choices:
B: Securing loose wires under carpeting can still pose a tripping hazard.
C: Using extension cords can lead to electrical hazards and fires.
D: Covering slippery stairs with an area rug can increase the risk of falls due to slipping.
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A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hr at a time.
- B. Instruct the client to take deep, rhythmic breaths.
- C. Apply an ice pack to the client's back for 1 hr.
- D. Remove distractions from the client's room.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to take deep, rhythmic breaths. Deep breathing helps promote relaxation, reduces muscle tension, and distracts the client from pain sensations. This can be an effective nonpharmacological pain relief method.
A: Encouraging the client to apply a heating pad for 2 hours at a time may exacerbate the pain if it's already mild.
C: Applying an ice pack for 1 hour may not be suitable for mild back pain as it is more effective for acute injuries.
D: Removing distractions may help, but it does not directly address the client's pain.
A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)
- A. While removing medication from the container
- B. Before selecting the medication container
- C. When documenting the medication administration
- D. When providing client education about the medication
- E. At the client's bedside before administering the medication
Correct Answer: A, B,E
Rationale: The correct answers are A, B, and E. Comparing the medication administration record against the container before removing the medication ensures accuracy. Before selecting the container, the nurse confirms the correct medication. At the client's bedside, the nurse verifies the medication before administration to prevent errors. Choice C is incorrect because documentation should occur after administration. Choice D is incorrect as medication reconciliation is not part of client education.
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
- A. Change the PN infusion bag every 48 hr.
- B. Obtain a random blood glucose daily.
- C. Prepare the client for a central venous line.
- D. Administer the PN and fat emulsion separately.
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for a central venous line. Parenteral nutrition (PN) with high dextrose concentrations can cause phlebitis and tissue damage if administered through a peripheral IV line. Therefore, a central venous line is appropriate for administering PN to prevent complications. Changing the PN bag every 48 hours (A) is important for infection control but not directly related to the administration method. Obtaining a random blood glucose daily (B) is important for monitoring glucose levels but does not address the administration method. Administering the PN and fat emulsion separately (D) is not necessary as they can be mixed in the same solution.
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
- A. The client turns their head against resistance.
- B. The client's tongue is in a midline position.
- C. The client's pupils constrict in response to light.
- D. The client has a symmetrical smile.
Correct Answer: D
Rationale: The correct answer is D: The client has a symmetrical smile. Cranial nerve VII, the facial nerve, controls facial expression including smiling. When assessing this nerve, the nurse would expect the client to have a symmetrical smile indicating intact function. This is because cranial nerve VII innervates the muscles of facial expression. Choices A, B, and C are incorrect as they are not specific to cranial nerve VII assessment. The turning of the head against resistance (A) would be more related to cranial nerve XI, the accessory nerve. The tongue position (B) is controlled by cranial nerve XII, the hypoglossal nerve. Pupillary constriction in response to light (C) is regulated by cranial nerve II, the optic nerve.