Nursing Elites

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. A nurse is reviewing the plan of care for a client who is receiving oxygen therapy. Which of the following interventions should the nurse include to prevent complications?

• A. Check the client's oxygen saturation every 2 hours
• B. Provide humidified oxygen
• C. Instruct the client to perform deep breathing exercises
• D. Use an oxygen mask for delivery

Correct answer: B

Rationale: The correct answer is B: Provide humidified oxygen. Providing humidified oxygen helps prevent dryness and irritation of the respiratory tract during oxygen therapy. This intervention is crucial in preventing complications such as mucous membrane dryness and potential damage to the airways. Checking the client's oxygen saturation every 2 hours (choice A) is essential for monitoring the client's response to therapy but does not directly prevent complications. Instructing the client to perform deep breathing exercises (choice C) is beneficial for respiratory function but does not directly address preventing complications related to oxygen therapy. Using an oxygen mask for delivery (choice D) is a common method of administering oxygen but does not specifically focus on preventing complications like dryness and irritation.

3. A healthcare provider is providing discharge instructions to a client with home oxygen. What is the most important safety consideration?

• A. Restrict fluid intake while using oxygen
• B. Ensure oxygen tanks are kept upright and away from heat sources
• C. Allow family members to smoke in designated areas
• D. Store oxygen tanks in a closet when not in use

Correct answer: B

Rationale: The correct answer is to ensure oxygen tanks are kept upright and away from heat sources. This is crucial to prevent any potential fire hazard, as oxygen supports combustion. Restricting fluid intake while using oxygen (choice A) is not necessary for oxygen safety. Allowing family members to smoke in designated areas (choice C) poses a significant fire risk. Storing oxygen tanks in a closet when not in use (choice D) is unsafe because proper ventilation is needed to prevent oxygen accumulation.

4. A client is expressing concern about extreme fatigue following an acute myocardial infarction. What is the best strategy to promote independence?

• A. Instruct the client to rest until fully recovered
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete self-care tasks
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence. This approach helps the client regain confidence and autonomy in performing self-care activities. Instructing the client to rest until fully recovered (Choice A) may lead to decreased muscle strength and independence. Assigning assistive personnel (Choice C) does not empower the client to actively participate in their care. Involving the client's family (Choice D) may provide support but does not directly encourage the client's independence.

5. A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?

• A. Use a phenol solution to clean the wound
• B. Place a warm compress over the wound
• C. Cleanse the wound from the center outwards
• D. Administer antibiotics prophylactically

Correct answer: C

Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.

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