A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Water heater temperature 54.4°C (130° F)

Throw rugs

Electric cords behind the furniture

Raised toilet seats

Bathtub with rails

Answer and Explanation

Correct Answer : A,B,C

A. A water heater temperature of 54.4°C (130°F) poses a burn risk, especially for older adults who may have decreased sensitivity to temperature changes. The recommended safe temperature for water heaters is usually around 49°C (120°F) to prevent scalding.

B. Throw rugs are a significant safety hazard as they can easily cause slips and falls, particularly for older adults who may have balance issues or mobility challenges.

C. Electric cords behind the furniture can create tripping hazards, especially if they are not secured properly or if the furniture is moved, leading to potential falls.

D. Raised toilet seats are typically considered a safety measure for older adults, as they can aid in sitting down and standing up, making it easier for individuals with mobility issues.

E. Bathtubs with rails are also a safety feature, providing support and stability for older adults when entering and exiting the tub, reducing the risk of falls.

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Correct Answer is B

Explanation

A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

A. The client who has a chest tube to water seal B. The client who has a tracheostomy tube attached to humidified oxygen C. The client who has an indwelling urinary catheter to gravity drainage D. The client who has a nasogastric (NG) tube to suction

Correct Answer is D

Explanation

A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.

B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.

C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.

D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.

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A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Correct Answer is B

Explanation

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

Correct Answer is D

Explanation

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

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A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

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