A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

The client's bed has a three-prong plug attached to the electrical cord.

A protective cover is inserted into an unused outlet.

An IV pump is plugged into an outlet near a sink.

An electrical cord is coiled and secured to the floor.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A three-prong plug attached to the electrical cord of the client's bed is not a safety hazard. It is a standard plug type used in many electrical devices and poses no immediate danger if properly installed.

Choice B rationale:

Inserting a protective cover into an unused outlet is actually a safety measure to prevent electrical accidents. It is not a hazard but a recommended practice.

Choice C rationale:

Plugging an IV pump into an outlet near a sink is a safety hazard. Water and electricity are a dangerous combination, and any spill or leakage around the outlet could lead to electrical shock or damage to the equipment.

Choice D rationale:

Coiling and securing an electrical cord to the floor can be a potential tripping hazard, but it is not as hazardous as having an electrical device near a sink. Tripping hazards can cause falls, while the combination of water and electricity is more likely to cause serious injuries.

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Correct Answer is A

Explanation

Choice A rationale:

The client's ABG values show a pH of 7.48, PCO2 of 30 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 85 mm Hg. The elevated pH and decreased PCO2 (respiratory component) suggest respiratory alkalosis. Respiratory alkalosis occurs when there is excessive ventilation, leading to a decrease in carbon dioxide levels (hypocapnia) and subsequent alkalosis.

Choice B rationale:

Respiratory acidosis is characterized by an elevated PCO2 and decreased pH. In this case, the client's PCO2 is decreased, indicating respiratory alkalosis rather than respiratory acidosis.

Choice C rationale:

Metabolic alkalosis is characterized by an elevated HCO3 (bicarbonate) level and an increased pH. The client's HCO3 level is within the normal range, making metabolic alkalosis an incorrect identification.

Choice D rationale:

Metabolic acidosis is characterized by a decreased HCO3 level and a decreased pH. The client's HCO3 level is within the normal range, ruling out metabolic acidosis as the acid-base imbalance in this case.

A. Assess the need for oral suction every 4 hr. B. Check the ventilator settings every 12 hr. C. Keep the head of the client's bed elevated at 30°. D. Perform oral hygiene using an alcohol-based oral rinse.

Correct Answer is C

Explanation

Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.

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A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are pH 7.48, PCO2 30 mm Hg, HCO3 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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