A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?

Wear clothing with zippers instead of buttons.

Place locks at the tops of exterior doors.

Replace the carpet with hardwood floors.

Encourage physical activity prior to bedtime.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Wearing clothing with zippers instead of buttons does not address the safety concerns related to Alzheimer's disease. This choice does not ensure the client's safety or prevent wandering, which are common issues in Alzheimer's patients.

Choice B rationale:

Placing locks at the tops of exterior doors is essential for the safety of clients with Alzheimer's disease. Alzheimer's patients often have a tendency to wander and may become disoriented, putting them at risk of getting lost or injured outside the home. Proper locks can prevent them from leaving the house unsupervised.

Choice C rationale:

Replacing the carpet with hardwood floors may reduce the risk of falls but does not specifically address the safety concerns related to Alzheimer's disease. It is important to focus on measures that prevent wandering and ensure the client's safety in various situations.

Choice D rationale:

Encouraging physical activity prior to bedtime is a good practice for promoting sleep in older adults but does not directly address the safety concerns of Alzheimer's patients. Safety measures, such as securing doors, supervising the client, and preventing wandering, are more crucial in this context.

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Correct Answer is B

Explanation

Choice A rationale:

Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.

Choice B rationale:

Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.

Choice C rationale:

Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.

Choice D rationale:

Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.

A. Eat a meal. B. Take pancrelipase. C. Use an albuterol inhaler. D. Complete oral hygiene.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Eating a meal prior to postural drainage is not recommended.Postural drainage uses gravity to help clear mucus from the lungs, and having a full stomach can cause discomfort and potentially lead to vomiting 1.

Choice B rationale: Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas.Most people with cystic fibrosis benefit from taking pancrelipase to aid their digestion 2. However, it is not specifically required prior to postural drainage.

Choice C rationale: Using an albuterol inhaler prior to postural drainage is beneficial.Albuterol is a bronchodilator that helps open the airways, making it easier to clear mucus from the lungs 3 4. This is why it’s recommended to use prior to postural drainage.

Choice D rationale: While maintaining good oral hygiene is important for overall health, it is not specifically required prior to postural drainage

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A home health nurse is planning care for a client who has Alzheimer's disease.Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

Correct Answer is C

Explanation

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A nurse is reinforcing teaching with a group of adolescents about safety.Which of the following information should the nurse include in the teaching?

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?