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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Palpating the dorsalis pedis pulse is an essential action to monitor for adequate circulation and perfusion in an extremity with an external fixator, which is a device that stabilizes and aligns fractured bones with metal pins and rods outside of the skin. The other options are incorrect because they could cause complications such as edema, infection, or malalignment.

A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is A

Explanation

The ABG results show a low pH (acidosis), a high PaCO2 (respiratory component), and a normal HCO3 (metabolic component). This indicates respiratory acidosis, which is caused by hypoventilation and retention of carbon dioxide.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

Correct Answer is A

Explanation

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has developed a heart rate of 38/min and reports tremors and feeling faint. Which of the following medications should the nurse anticipate administering?

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?

A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?

A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?