during a home visit the nurse finds that an elderly client has multiple expired medications what should the nurse do first
Logo

Nursing Elites

HESI RN

Community Health HESI

1. During a home visit, the nurse finds that an elderly client has multiple expired medications. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for the nurse to take when finding multiple expired medications in an elderly client's home is to review the client's current medication regimen. This step is crucial to identify any potential issues, ensure the client is taking the correct medications, and understand why the expired medications were not used. Instructing the client to dispose of the expired medications (Choice A) can come after understanding the current medication situation. Contacting the client's healthcare provider (Choice C) may be necessary but reviewing the medication regimen should be the initial step. Educating the client on the dangers of taking expired medications (Choice D) is important but should be done after addressing the immediate concern of reviewing the current medications.

2. An 80-year-old client is given morphine sulfate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?

Correct answer: C

Rationale: The correct answer is C: Tricyclic antidepressants. Drugs with anticholinergic properties, such as tricyclic antidepressants, can exacerbate urinary retention associated with opioids in older clients. Nonsteroidal anti-inflammatory agents (Choice A) do not typically cause urinary retention. Antihistamines (Choice B) may cause urinary retention but are not the primary concern in this scenario. Antibiotics (Choice D) are not associated with an increased risk of urinary retention compared to tricyclic antidepressants.

3. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

4. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.

5. A client with a history of hypertension is admitted with a blood pressure of 200/120 mm Hg. Which medication should the nurse prepare to administer?

Correct answer: D

Rationale: The correct answer is D, Nitroprusside (Nipride). In this scenario of severe hypertension (200/120 mm Hg), a hypertensive emergency is present, requiring rapid reduction of blood pressure. Nitroprusside is a vasodilator that acts quickly to lower blood pressure in such emergencies. Options A, B, and C are incorrect: A) Metoprolol is a beta-blocker that lowers blood pressure but is not indicated for hypertensive emergencies requiring rapid reduction. B) Furosemide is a diuretic that helps with fluid retention but does not rapidly lower blood pressure. C) Lisinopril is an ACE inhibitor used for long-term management of hypertension, not for immediate reduction in hypertensive emergencies.

Similar Questions

A client with hyperthyroidism is receiving radioactive iodine therapy. Which statement by the client indicates a need for further teaching?
A community health nurse is addressing the issue of elder abuse in the community. Which intervention should be prioritized?
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?
When planning a community health fair to promote mental health awareness, which activity should be included to best engage participants?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses