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A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?
- A. Encourage physical activity prior to bedtime
- B. Replace the carpet with hardwood floors
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the top of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.
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A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery.
Which of the following actions should the nurse take to promote learning?
- A. Speak loudly when addressing the client
- B. Connect new information with the client's past experiences
- C. Present the information to the client using abstract concepts
- D. Use a 12 point font when printing written material for the client
Correct Answer: B
Rationale: The correct answer is B: Connect new information with the client's past experiences. This promotes learning by linking new concepts to existing knowledge, aiding in retention and understanding. Speaking loudly (A) may not enhance learning and can be off-putting. Presenting information abstractly (C) may confuse the client. Using a 12 point font (D) is a formatting preference and does not directly impact learning.
A nurse is caring for a client who has placenta previa.
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.
A nurse is providing preoperative teaching to a client about the administration of morphine via a PCA pump.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will receive a limited amount of pain medication when I press the button.
- B. I should have my family press the button for me when I am asleep.
- C. I can receive as much pain medication as I need by pressing the button.
- D. I should wait until my pain is severe before using the PCA pump.
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the concept of patient-controlled analgesia (PCA) pump, where they will receive a limited amount of pain medication when they press the button. This indicates the client knows they have control over their pain relief.
Choice B is incorrect as having someone else press the button goes against the purpose of PCA, which is for the patient to self-administer medication. Choice C is incorrect because unlimited medication can lead to overdose. Choice D is incorrect as waiting for severe pain can lead to ineffective pain management.
The nurse is discussing discharge plans with an older adult client who lives alone and has left sided weakness following a stroke
Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individual who have had a stroke
- B. obtaining an alert system to get help in case of a fall
- C. providing information about available transportation resources
- D. choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: obtaining an alert system to get help in case of a fall. This is the priority for the nurse to discuss because falls can lead to serious injuries, so having a system in place to quickly get help is crucial for the patient's safety. Reviewing support groups (A) is important but not as urgent as fall prevention. Transportation resources (C) and home physical therapy agency (D) are important but secondary to immediate safety concerns.
A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client.
Which of the following actions should the nurse take first?
- A. Review the client's allergy history.
- B. Monitor the client's temperature.
- C. Check the client's latest white blood cell(WBC) count.
- D. Explain the purpose of the medication to the client.
Correct Answer: A
Rationale: The correct answer is A: Review the client's allergy history. This should be done first to prevent potential harm to the client from allergic reactions. Knowing the client's allergy history helps the nurse identify any potential risks associated with administering medications. Monitoring temperature (B) and checking WBC count (C) are important but come after ensuring the safety of medication administration. Explaining the purpose of medication (D) is important but should be done after ensuring the client's safety.