Nokea
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
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The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
- A. I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection
- B. I will need to take deep breaths and cough hourly
- C. I will have to attend physical therapy sessions following my surgery
- D. I will be prescribed an anticoagulant and need to take it with a sip of water before the surgery
Correct Answer: D
Rationale: Taking an anticoagulant with a sip of water before surgery is incorrect, as clients are typically NPO, and anticoagulants like enoxaparin are administered post-operatively to prevent thromboembolism. The other statements are correct regarding infection prevention, respiratory exercises, and physical therapy.
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
- A. Assess the surgical wound
- B. Collect blood cultures
- C. Administer oxygen at 2 L/minute
- D. Encourage by-mouth (PO) fluids
Correct Answer: C
Rationale: Changes in vital signs post-surgery may indicate respiratory or circulatory compromise. Administering oxygen at 2 L/minute is a prudent initial action to support oxygenation while further assessment occurs. Wound assessment, blood cultures, or fluids require specific clinical indications.
The nurse is working with a group of students and a student asks what cyanosis means. What is the nurse's best response?
- A. Cyanosis is a condition characterized by a yellowish discoloration of the skin and mucous membranes due to excessive oxygenation.
- B. Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood.
- C. Cyanosis is the primary indication that the client has pneumonia.
- D. Cyanosis is the bluish discoloration of the skin and mucous membranes due to poor peripheral circulation, even in the presence of normal oxygen levels.
Correct Answer: B
Rationale: Cyanosis is blue discoloration due to poorly oxygenated blood. Yellowish discoloration is jaundice, it’s not specific to pneumonia, and circulation issues alone don’t cause it if oxygen is normal.
The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.
- A. Obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.
- B. Places the BP cuff over the client's clothing garment.
- C. Requests the client remove their hearing aid before obtaining a tympanic temperature.
- D. Assesses the client's respirations after obtaining the pulse rate.
- E. Obtains blood pressure by placing the client's upper extremity at the level of their heart.
- F. Places the pulse oximeter probe on the client's finger that has edema.
Correct Answer: B,F
Rationale: Placing the BP cuff over clothing and using an edematous finger for pulse oximetry can yield inaccurate readings. Other actions are correct.
A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling?
- A. Encouraging the client to ambulate independently to improve muscle strength.
- B. Verify that the bed alarm is enabled during client rounding.
- C. Implementing a fall risk assessment every two days
- D. Implementing a restrictive mobility policy to minimize the potential of falls.
Correct Answer: B
Rationale: Verifying the bed alarm ensures immediate notification of movement, reducing fall risk for a client with a fall history.