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1. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?
- A. Educate the client about their current medical diagnosis.
- B. Refer the client to a meal delivery program.
- C. Identify environmental hazards in the home.
- D. Arrange transportation for the client to follow-up appointments.
Correct answer: C
Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.
2. What are the nursing priorities for a patient experiencing an asthma exacerbation?
- A. Administer a bronchodilator
- B. Encourage deep breathing
- C. Provide oxygen therapy
- D. Monitor oxygen saturation
Correct answer: A
Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.
3. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?
- A. Iron 90 mcg/dl.
- B. Prealbumin 10 mcg/dl.
- C. Serum creatinine 0.8 mg/dl.
- D. Calcium 9.5 mg/dl.
Correct answer: B
Rationale: Corrected Rationale: Low prealbumin levels are indicative of malnutrition, which is common in individuals with anorexia nervosa. Iron levels, serum creatinine, and calcium levels are not typically affected in the same way by anorexia nervosa, making choices A, C, and D incorrect.
4. A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse about measures to improve breathing. Which of the following instructions should the nurse include?
- A. Use pursed-lip breathing during physical activity
- B. Breathe deeply and quickly during exercise
- C. Avoid using the incentive spirometer
- D. Avoid physical activity to conserve energy
Correct answer: A
Rationale: The correct instruction the nurse should include is to 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a technique that helps improve breathing efficiency in individuals with COPD by preventing airway collapse and allowing for better air exchange. Choice B is incorrect because breathing deeply and quickly can lead to hyperventilation and worsen symptoms in COPD patients. Choice C is incorrect because the incentive spirometer is a device used to encourage deep breathing and improve lung function, so it should not be avoided. Choice D is incorrect because physical activity is important for maintaining overall health and should be encouraged in a controlled and appropriate manner for individuals with COPD.
5. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?
- A. Prohibit smoking near oxygen equipment
- B. Ensure the client uses non-flammable bedding
- C. Ensure oxygen tanks are stored upright
- D. Keep the oxygen equipment at least 6 feet away from heat sources
Correct answer: D
Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.
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