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A home care nurse is assisting with the care of a client.

Exhibits
The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.

Urinary stasis

Calcium resorption

Contractures

Hypocalcemia

Hypertension

Diarrhea

Pressure ulcer

Atelectasis

Answer and Explanation

Correct Answer : A,B,C,G,H

Rationale:
• Urinary stasis: Immobility slows bladder emptying and ureteral flow, increasing residual urine. This promotes bacterial growth and risk of urinary tract infection. MS clients with decreased mobility are especially vulnerable.

• Calcium resorption: Bone demineralization occurs during prolonged immobility. Without weight-bearing, calcium is released from bone into the bloodstream, raising serum calcium and weakening bones.

• Contractures: Lack of movement leads to shortening and stiffening of muscles and joints. Over time, joints lose flexibility, especially if the client remains curled in one position.

• Hypocalcemia: The client is more likely to develop hypercalcemia due to calcium resorption from bones. There's no evidence of low calcium symptoms like tetany or numbness.

• Hypertension: The client's vital signs are within normal range. Immobility may reduce cardiac output over time, but it does not typically cause high blood pressure.

• Diarrhea: Immobility usually causes constipation due to slowed peristalsis. There's no report of active GI symptoms or triggers for diarrhea in this case.

• Pressure ulcer: Continuous pressure on one area reduces capillary blood flow. This leads to tissue ischemia and skin breakdown, especially over bony prominences like the hip and shoulder.

• Atelectasis: Lying on one side restricts lung expansion, and refusal to change positions impairs ventilation. This can cause alveolar collapse and decreased oxygen exchange.

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Correct Answer is D

Explanation

Rationale:

A. Gown: The gown should be removed after the gloves because it may be contaminated but has less direct contact with infectious material. Removing it after gloves helps reduce the risk of spreading pathogens from the hands to the clothing or environment.

B. Mask: The mask is usually removed last to prevent inhalation of airborne or droplet contaminants during PPE removal. Premature removal may expose the nurse to infectious particles still present in the surrounding air.

C. Eyewear: Goggles or face shields should be removed after gloves to avoid contamination of the face during removal. Touching the eyewear with potentially contaminated gloves could transfer pathogens close to the eyes or face.

D. Gloves: Gloves are the most contaminated PPE item due to direct patient contact and should be removed first. This limits the risk of transferring pathogens from the gloves to other PPE or surfaces during the removal process.

A. Notify the unit manager. B. Collect data on the client. C. Notify the provider. D. Complete an incident report.

Correct Answer is B

Explanation

Rationale:

A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.

B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.

C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.

D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.

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A home care nurse is assisting with the care of a client. Exhibits The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.

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A home care nurse is assisting with the care of a client.

Exhibits
The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.