the home health nurse has made a visit to an 85 year old female clients home who has recently had surgery to replace her left knee the client has been
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Nursing Elites

NCLEX-PN

NCLEX PN Practice Questions Quizlet

1. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

2. A nurse assisting with data collection is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?

Correct answer: A

Rationale: Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly between five and 30 times a minute. In this scenario, since the client ate lunch just 45 minutes ago, the nurse would expect to note gurgling sounds as normal bowel activity. Hypoactive sounds (low-pitched) or an absence of sounds are usually associated with conditions such as abdominal surgery or inflammation of the peritoneum, not with recent food intake. Therefore, the correct answer is gurgling sounds, indicating normal bowel activity following a recent meal.

3. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

4. When assisting with data collection on language development in a toddler from a bilingual family, what characteristic would a nurse expect?

Correct answer: C

Rationale: When assessing language development in a toddler from a bilingual family, a nurse would expect the child's language development to be slower than expected. Various factors, such as physical maturity and reinforcement received, can influence the pace of language development. Children from bilingual families, twins, and non-firstborn children may exhibit slower language development. Therefore, it is common for the language development of a toddler from a bilingual family to be slower than expected. This characteristic does not necessarily imply a need for speech therapy. Choices A, B, and D are incorrect because, in this context, the language development of the child is more likely to be slower than expected rather than more advanced, developing as expected, or requiring speech therapy.

5. As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?

Correct answer: C

Rationale: The correct answer is C: 'says 'Mine!' when playing with toys.' At the age of 2, children are in the stage of parallel play and are possessive of their belongings, hence saying 'Mine!' is an age-appropriate behavior. Building towers with blocks (choice A) involves more advanced motor skills and cognitive abilities, which are beyond what most 2-year-olds can do. Trying to color within the lines (choice B) requires fine motor skills that are typically not developed at age 2. Jumping rope (choice D) involves coordination and balance that are beyond the capabilities of a 2-year-old child.

Similar Questions

A client states, "I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?"? The nurse should respond with which of the following statements?
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After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

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