A community health nurse is performing a home health admissions assessment with a client. The client reports being unable to obtain their prescriptions. Which of the following actions should the nurse take first?

Notify the client's family member regarding their inability to obtain prescriptions.

Call the local pharmacist on behalf of the client.

Assess the barriers to the client's ability to obtain prescriptions.

Initiate a referral to a social worker.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Notify the client’s family member regarding their inability to obtain prescriptions: Involving family members can be helpful later, but the nurse must first understand why the client cannot obtain medications before deciding whether family assistance is necessary.

B. Call the local pharmacist on behalf of the client: Contacting the pharmacist may help resolve access issues such as refills or delivery, but this step is premature without identifying the specific barriers that prevent the client from getting medications.

C. Assess the barriers to the client’s ability to obtain prescriptions: The first action is assessment to determine the root cause of the problem. Barriers may include lack of transportation, financial hardship, limited mobility, or misunderstanding of the prescription process. Once the cause is identified, appropriate interventions or referrals can be made.

D. Initiate a referral to a social worker: A social worker can assist with financial or community resources, but the nurse should first gather assessment data to provide accurate information for an effective referral.

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Correct Answer is B

Explanation

Rationale:
A. Skin warm and dry: Warm, dry skin indicates adequate circulation and fluid balance. In fluid overload, the skin is often cool and moist due to peripheral vasodilation and increased interstitial fluid. Therefore, this finding is not consistent with overhydration.

B. Respiratory rate 30/min: Tachypnea is a key indicator of fluid overload because excess fluid can accumulate in the lungs, leading to pulmonary congestion and decreased gas exchange. The body compensates by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide.

C. Heart rate 60/min: A normal heart rate suggests stable cardiovascular status. Fluid overload typically causes tachycardia as the heart works harder to manage increased circulatory volume, not a normal or bradycardic rate.

D. Tenting skin turgor: Tenting indicates dehydration, not fluid overload. In overhydration, the skin is usually taut and edematous due to excess interstitial fluid accumulation rather than loss of elasticity.

A. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse. B. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min. C. Measure the client's apical pulse while another nurse measures their radial pulse. D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations.

Correct Answer is C

Explanation

Rationale:
A. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This technique assesses blood pressure, not pulse deficit. Pulse deficit requires comparing simultaneous heartbeats at different sites rather than using a cuff for measurement.

B. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This evaluates orthostatic changes in heart rate, not pulse deficit. Pulse deficit specifically identifies a difference between apical and peripheral pulses during the same cardiac cycle.

C. Measure the client's apical pulse while another nurse measures their radial pulse: A pulse deficit is determined by counting the apical pulse and comparing it to the radial pulse simultaneously. A difference indicates that some heartbeats are not producing a palpable peripheral pulse, which is important in conditions like atrial fibrillation.

D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing radial pulses on both sides evaluates for peripheral pulse equality or arterial obstruction, not pulse deficit.

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A community health nurse is performing a home health admissions assessment with a client. The client reports being unable to obtain their prescriptions. Which of the following actions should the nurse take first?

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