A home health nurse is providing care to an older adult client during the winter. During an in-home visit, the nurse notes that the thermostat is set to 12.8° C (55° F). The client tells the nurse, "I keep the heat set low because I can't afford to pay the bill." Which of the following actions should the nurse take?
Recommend staying at a local shelter until the client can afford the bill.
Contact the local Department of Health and Human Services for the client.
Contact the client's family members to tell them the client's financial status.
Provide the client with written information about the dangers of hypothermia.
The Correct Answer is B
The nurse should contact the local Department of Health and Human Services for the client, as this agency may be able to provide assistance with heating costs or other resources for low-income individuals.
Older adults are at increased risk of hypothermia, which is a potentially life-threatening condition that occurs when body temperature drops below 35° C (95° F). Hypothermia can be caused by exposure to cold temperatures, inadequate clothing, poor nutrition, chronic illness, or medication use. Therefore, it is important for the nurse to intervene and help the client maintain a safe and comfortable home environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.
The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.
Correct Answer is B
Explanation
The nurse should obtain a blood pressure reading using only the left extremity from a client who has a right upper extremity arteriovenous fistula. An arteriovenous fistula is a surgical connection between an artery and a vein that is created for hemodialysis access.
Measuring blood pressure on the arm with an arteriovenous fistula can cause damage to the fistula, reduce blood flow, and increase the risk of infection or thrombosis. Therefore, blood pressure should be measured on the opposite arm or on another site such as the leg.
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