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A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
- A. Have the client wear a surgical mask during transport.
- B. Wear an N95 mask while providing care to the client.
- C. Administer an influenza immunization to the client.
- D. Place the client in a negative airflow room.
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
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A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?
- A. Place white tape on the edges of stairs.
- B. Place area rugs on wooden floors.
- C. Run wires and cords under carpeting.
- D. Have the furnace inspected every 2 years.
Correct Answer: A
Rationale: White tape on stair edges improves visibility, reducing fall risk in older adults. Rugs and hidden cords are trip hazards, and furnace checks should be annual, not biennial.
A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use ibuprofen when I have a headache.
- B. I will use an electric razor for shaving
- C. I will avoid the use of stool softeners.
- D. I will massage the site after each injection.
Correct Answer: B
Rationale: Using an electric razor reduces bleeding risk with enoxaparin, an anticoagulant. Ibuprofen increases bleeding, stool softeners may be needed, and massaging injection sites is contraindicated.
A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective?
- A. I continue to lose weight.
- B. I have less oily skin.
- C. I no longer feel nervous.
- D. I no longer take a stool softener.
- E. I feel more tired.
- F. My appetite has decreased.
- G. My heart rate is faster.
Correct Answer: C
Rationale: Reduced nervousness indicates propylthiouracil is controlling hyperthyroid symptoms like anxiety.
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. You will not become fatigued when you use assistive devices.
- B. Plan to hire a home care aid to perform all of your ADLs.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping
Correct Answer: C
Rationale: Grab bars enhance safety and independence in the shower post-CVA. Fatigue is possible, full assistance isn't always needed, and a towel could be a slip hazard.
A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
- A. Leave the television on in the client's room
- B. Raise all four side rails while the client is in bed.
- C. Move the overbed table away from the bed.
- D. Apply a motion sensor mat to the client's bed
Correct Answer: D
Rationale: A motion sensor mat alerts staff to movement, reducing fall risk in dementia clients. TV can agitate, four rails are a restraint, and moving the table doesn't directly prevent falls.