A home health nurse is conducting a home-safety risk appraisal 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)

Electric cords behind furniture

Bathtub with rails

Raised toilet seats

Throw rugs

Answer and Explanation

Correct Answer : A,B,E

A. Water heater temperature 54.4°C (130° F):

This water heater temperature is too high and poses a scalding risk. The recommended temperature setting for water heaters is generally below 49°C (120° F) to prevent burns.

B. Electric cords behind furniture:

Placing electric cords behind furniture can create tripping hazards. It is safer to have cords organized and placed away from areas where the client may walk.

C. Bathtub with rails:

Having a bathtub with rails is a safety feature that can assist the client in getting in and out of the bathtub safely. It is not a safety risk.

D. Raised toilet seats:

Raised toilet seats are often recommended for older adults to facilitate safe and easier use of the toilet. They are not a safety risk when used appropriately.

E. Throw rugs:

Throw rugs can be a tripping hazard, especially for older adults who may have mobility issues. They should be secured or removed to prevent falls.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Instruct the clients to use the call light.

Encouraging clients to use the call light enables them to request assistance when needed, reducing the risk of falls if they need help to move or get out of bed.

B. Move overbed tables away from the bed.

Clearing the area around the bed, including overbed tables, reduces obstacles and potential hazards that clients might trip over or get tangled in.

C. Place a fall risk wristband on each of the clients.

Identifying clients at risk for falls by using wristbands helps alert all healthcare staff to take necessary precautions and provide appropriate assistance to prevent falls.

D. Perform client checks every 4 hr.

Regular client checks allow the nurse to monitor their condition, reposition them if necessary, assist with toileting needs, and ensure they're safe, especially during the night when falls might be more likely.

E. Keep the clients' rooms dark.

Keeping the room dimly lit during the night can help clients sleep better but should still provide enough light for safe movement. Complete darkness might increase the risk of falls if clients need to move around.

A. Request a dietary consult. B. Check the client's vital signs. C. Request an order for an antiemetic. D. Suggest that the client rests before eating the meal.

Correct Answer is B

Explanation

A. Request a dietary consult:

While dietary concerns may be addressed, checking vital signs is the priority when a client reports nausea, especially in the context of medication administration.

B. Check the client's vital signs:

This is the correct action. Nausea can be a symptom of digoxin toxicity. Checking vital signs, especially assessing for changes in heart rate, is crucial in determining whether the client is experiencing adverse effects of digoxin.

C. Request an order for an antiemetic:

Administering an antiemetic may be considered later, but the first priority is to assess the client's vital signs and determine if the nausea is related to digoxin toxicity.

D. Suggest that the client rests before eating the meal:

Resting before eating may be helpful for nausea, but the priority is to assess the client's vital signs and determine the cause of the nausea, especially in the context of digoxin use.

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A home health nurse is conducting a home-safety risk appraisal 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 working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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