A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Record information about the home visit according to agency policy.
Contact the family to determine availability and readiness to make an appointment.
Discuss plans for future visits with the family.
Clarify the reason for the referral with the provider's office.
Identify family needs and interventions using the nursing process.
The Correct Answer is D,B,E,C,A
Rationale:
A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.
B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.
C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.
D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.
E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urinary output 20 mL/hr: A urinary output less than 30 mL/hr in an adult indicates potential renal hypoperfusion or urinary retention. This is a priority finding that should be reported to the provider promptly.
B. Serous drainage on abdominal dressing: Serous drainage is a normal postoperative finding, indicating normal wound healing and fluid exudate. It does not require immediate provider notification.
C. Temperature 37.6° C (99.7° F): This temperature is slightly elevated but within the expected postoperative range due to the inflammatory response. It does not indicate an urgent complication.
D. Blood pressure 100/70 mm Hg: This blood pressure is within normal limits for many adults and is not necessarily concerning in a postoperative context unless accompanied by other symptoms such as tachycardia or dizziness.
Correct Answer is A
Explanation
Rationale:
A. "The nurse will ask you to remove any transdermal patches prior to the procedure.": Some transdermal patches contain metallic components that can overheat during an MRI, posing a burn risk. Removing them prevents injury and ensures safety in the strong magnetic field.
B. "The nurse will ask you to wear protective eyewear during this procedure.": Protective eyewear is not necessary for MRI scans, as there is no exposure to bright light or flying debris. This precaution applies more to procedures involving lasers or potential eye hazards.
C. "You should not have this procedure if you are allergic to iodine.": Iodine allergies are a concern with certain CT scans using iodinated contrast, not standard MRIs. MRI contrast agents typically contain gadolinium, which has a different allergy profile.
D. "You should not have this procedure if you have a tattoo.": Tattoos generally do not contraindicate MRI, although some with metallic ink may cause mild skin irritation. This is rare and does not usually prevent the procedure from being performed.
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