Nokea
The home health nurse enters the home of a client, and the client's spouse immediately reports that the client cannot be awakened and appears to have taken an overdose of some medications. After determining that the client is unresponsive but is breathing and has a pulse, which action should the nurse take?
- A. Call 911 for emergency transport.
- B. Determine what medications were ingested.
- C. Contact the poison control center.
- D. Attempt to induce vomiting using a tongue blade.
Correct Answer: A
Rationale: Calling 911 ensures immediate medical intervention for an unresponsive client, critical to address a potential overdose.
You may also like to solve these questions
A school nurse identifies 15 new students with positive tuberculin tests among the 500 at-risk students tested. Which is the rate per 1,000 with new positive tests?
- A. 3/1,000.
- B. 30/1,000.
- C. 1.7/1,000.
- D. 15/1,000.
Correct Answer: B
Rationale: The rate is calculated as (15/500) * 1,000 = 30/1,000, accurately reflecting the proportion of students with positive tests per 1,000.
A prescription for discharge is written for an elderly client who has asked to be discharged to home. The client lives alone and is able to walk 10 to 15 feet (3 to 4.5 meters) with assistance. Which action should the nurse implement first?
- A. Review the home medication schedule with the client and family.
- B. Provide the client with information about medical alert devices.
- C. Arrange for a bedside commode to be delivered to the home.
- D. Meet with the case manager to plan a home safety evaluation.
Correct Answer: D
Rationale: A home safety evaluation is critical to identify hazards and ensure the client's limited mobility is accommodated, preventing falls and ensuring safety.
While presenting a workshop titled, 'Improving Access to Health Services' to community leaders, the community health nurse is asked by a city council member to explain the reason for addressing this issue. Which statement provides the best response?
- A. The Centers for Disease Control and Prevention (CDC) has identified this problem as a variable in morbidity.
- B. The Community Health Improvement Process is used for issues in high risk populations.
- C. The Institute of Medicine includes 'access' as one of its priority recommendations.
- D. The committee for 'Healthy People 2030' has identified 'access' as a national goal.
Correct Answer: D
Rationale: Healthy People 2030' identifies access as a national goal, underscoring its importance in public health, making it a compelling reason for addressing the issue.
A homeless client with alcohol dependency will be dismissed from the emergency department in 24 hours. The nurse notes that a tuberculin (TB) skin test was prescribed by the healthcare provider. Which intervention is most important for the nurse to implement prior to discharge?
- A. Explain to the client results should be read between 48 and 72 hours.
- B. Identify how the client will follow up to have the results read.
- C. Determine if the client understands the purpose of the tuberculin test.
- D. Give the client written Information about the tuberculosis test.
Correct Answer: B
Rationale: Ensuring follow-up for TB test reading is critical, especially for a homeless client, to confirm diagnosis and prevent missed results.
The community health nurse believes that immunization rates in a lower-socioeconomic section of the city are probably below the target set by the state health department. Which action should the nurse take first to intervene with this health problem?
- A. Review current epidemiological population data that might document a low immunization rate.
- B. Call a meeting of citizens to inform them of the importance of having their children immunized.
- C. Join a political action group that focuses attention on the issue in the local news media.
- D. Partner with a local children's hospital in setting up free 'shot' clinics in the neighborhood.
Correct Answer: A
Rationale: Reviewing epidemiological data confirms the extent of low immunization rates, providing a foundation for targeted interventions.