Nokea
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails?
- A. Shufling gait.
- B. Urinary incontinence.
- C. Syncope when bending.
- D. Hand tremors.
Correct Answer: A,C,D
Rationale: Mobility and dexterity issues necessitate foot care assistance.
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An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?
- A. Teach the client alternative ways to manage chronic pain.
- B. Instruct the client to take the morphine sulfate every 12 hours as prescribed.
- C. Tell the client to continue taking the morphine sulfate with severe pain.
- D. Explain the risk of drug addiction from long-term pain medications.
Correct Answer: B
Rationale: Scheduled dosing maintains consistent pain control.
While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?
- A. Unpleasant odor of the breath
- B. White patches on the mucosa.
- C. Gumline that has visibly receded.
- D. Discoloration of several teeth.
Correct Answer: B
Rationale: White patches suggest thrush requiring treatment.
The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?
- A. Print the electronic medical record (EMR) from a backup server.
- B. Identify information as a late entry in the record.
- C. Wait for notification that the system has been rebooted.
- D. Notify the information services department of the situation.
Correct Answer: D
Rationale: Notifying IT resolves system issues promptly.
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
- A. Bowel incontinence.
- B. Impaired bed mobility.
- C. Fluid volume deficit.
- D. Caregiver role strain.
Correct Answer: C
Rationale: Dehydration from diarrhea is life-threatening.
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Document the site where the medication was given.
- B. Notify the healthcare provider of the allergic response.
- C. Elevate the area and apply light pressure over the site.
- D. Apply a cold pack to the area for twenty minutes.
Correct Answer: A
Rationale: Wheal is normal and should be documented.