A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

The hot water heater is set to 47° C (117° F).

Grab bars are installed in the shower.

There is an area rug covering a tile floor.

Prescriptions are stored in a medication organizer.

Answer and Explanation

The Correct Answer is C

A. The hot water heater is set to 47° C (117° F). This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.

B. Grab bars are installed in the shower. Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.

C. There is an area rug covering a tile floor. Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.

D. Prescriptions are stored in a medication organizer. A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.

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Correct Answer is A

Explanation

A.Ensuring the client's heels are not touching the mattress: Pressure injuries, particularly on the heels, are common in clients who are immobile and on bed rest. Elevating the heels off the mattress helps to alleviate pressure and reduce the risk of developing pressure injuries in this area.

B.Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.

C.Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.

D, Reposition the client every 4 hr.

Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.

A. Use a quick-release knot to secure the ties. B. Cut the old ties after the new ties are secured. C. Allow space for three fingers under the ties when securing. D. Extend the client's neck while securing the ties

Correct Answer is B

Explanation

Correct answer: B

A. Use a quick-release knot to secure the ties:

This is not the best practice. Quick-release knots are not recommended for securing tracheostomy ties because they can loosen more easily, increasing the risk of accidental decannulation (dislodging the tracheostomy tube). The ties should be securely fastened with a non-quick-release knot.

B. Cut the old ties after the new ties are secured:

This is the safest approach. It ensures the tracheostomy tube remains secure throughout the change.

C. Allow space for three fingers under the ties when securing:

Two fingers is the recommended space to allow for breathing comfort and prevent the tube from being too loose..

D. Extend the client's neck while securing the ties:

This is not the correct action. Hyperextending the client's neck during tracheostomy tie changes can cause discomfort and may compromise the integrity of the tracheostomy tube placement. The neck should be in a neutral position to maintain proper alignment.

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A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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